SPRINGER BRIEFS IN APPLIED SCIENCES AND

TECHNOLOGY  SAFET Y MANAGEMENT

Benoît Journé
Hervé Laroche
Corinne Bieder
Claude Gilbert Editors

Human and
Organisational
Factors
Practices and
Strategies for a
Changing World
SpringerBriefs in Applied Sciences
and Technology

Safety Management

Series Editors
Eric Marsden, FonCSI, Toulouse, France
Caroline Kamaté, FonCSI, Toulouse, France
François Daniellou, FonCSI, Toulouse, France
The SpringerBriefs in Safety Management present cutting-edge research results on
the management of technological risks and decision-making in high-stakes settings.
Decision-making in high-hazard environments is often affected by uncertainty and
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Managers and regulators need conceptual tools to help them develop risk
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These publications are by and for academics and practitioners (industry, regulators)
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treated.
The SpringerBriefs in Safety Management series is coordinated by the Foundation
for an Industrial Safety Culture (FonCSI), a public-interest research foundation
based in Toulouse, France. The FonCSI funds research on industrial safety and the
management of technological risks, identifies and highlights new ideas and
innovative practices, and disseminates research results to all interested parties.

For more information: https://www.foncsi.org/.

More information about this subseries at http://www.springer.com/series/15119

Benoît Journé Hervé Laroche
• •

Corinne Bieder Claude Gilbert

•

Editors

Human and Organisational

Factors
Practices and Strategies for a Changing World
Editors
Benoît Journé Hervé Laroche
IAE Economie et Management ESCP Europe
Université de Nantes Paris, France
Nantes, France

Corinne Bieder Claude Gilbert

Ecole Nationale de l'Aviation Civile Institut d’Etudes Politiques
Toulouse, France CNRS
Grenoble, France

ISSN 2191-530X ISSN 2191-5318 (electronic)

SpringerBriefs in Applied Sciences and Technology
ISSN 2520-8004 ISSN 2520-8012 (electronic)
SpringerBriefs in Safety Management
ISBN 978-3-030-25638-8 ISBN 978-3-030-25639-5 (eBook)
https://doi.org/10.1007/978-3-030-25639-5
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Foreword

The industrial partners of the Foundation for an industrial safety culture (FonCSI)
are convinced of the importance of considering human and organisational factors
(HOF) for safety. Many companies are keen for them to be considered in their
industrial safety policy, albeit at different paces. However, some issues remain
unclear, the first one being that, depending on their context, companies can face
difficulties in defining the notions of HOF and industrial safety. Beyond this
observation, many questions are asked regarding which HOF strategies to imple-
ment, and for what purpose.
What are the concepts, the approaches by discipline and the professions
(ergonomists, human factors specialists, sociologists, etc.) that need to be mobi-
lised? How can a HOF approach to industrial safety be structured in a large group?
Should it be centralised or organised according to the specific features of activities
and local contexts? How should the role of HOF experts be organised? How can the
extent of the company’s inclusion of HOF be evaluated? What are the indicators
that allow the degree of maturity and the progress needed to be measured?
This collective book is the fruit of the reflexions and debates of the third ‘strategic
analysis’ conducted by the Foundation for an industrial safety culture. The project was
simply entitled ‘Human & organisational factors in high-risk companies’ and sought
to provide FonCSI’s industrial partners with high-level research results within a
limited time. The book notably presents the very valuable contributions of interna-
tional experts who were invited to expose and confront their viewpoints during a 2-day
residential seminar, the highlight of the strategic analysis, that was held in January
2018. The book explores the questions raised above with an emphasis on examples
and lessons learned based on the field experience of its authors who come from
different academic disciplines and various industrial sectors such as oil and gas,
energy and transportation. It then offers some ways forward for a better consideration
of human and organisational factors in hazardous companies with a view to promoting
safety and facing the challenges of a rapidly changing world.

Toulouse, France FonCSI

v
Contents

What Is the Place of Human and Organisational Factors

in Safety? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Claude Gilbert
Accounting for Differing Perspectives and Values:
The Rail Industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Brendan Ryan
Safety Leadership and Human and Organisational Factors
(HOF)—Where Do We Go from Here? . . . . . . . . . . . . . . . . . . . . . . . . . 15
Kathryn J. Mearns
Considering Human and Organizational Factors in Risk
Industries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Christian Neveu, Valerie Lagrange, Philippe Noël and Nicolas Herchin
The Key Drivers to Setting up a Valuable and Sustainable HOF
Approach in a High-Risk Company such as Airbus . . . . . . . . . . . . . . . . 31
Florence Reuzeau
Developing Human and Organizational Factors in a Company . . . . . . . 41
François Daniellou
Organisational Factors, the Last Frontier? . . . . . . . . . . . . . . . . . . . . . . 49
Ivan Boissieres
Risk Management and Judicialization . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Caroline Lacroix
Integrating Organizational and Management Variables
in the Analysis of Safety and Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Paul R. Schulman

vii
viii Contents

Turning the Management of Safety Risk into a Business Function:

The Challenge for Industrial Sociotechnical Systems
in the 21st Century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Daniel Mauriño
The Strategic Agility Gap: How Organizations Are Slow
and Stale to Adapt in Turbulent Worlds . . . . . . . . . . . . . . . . . . . . . . . . 95
David D. Woods
The Languages of Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Herve Laroche
The Dual Face of HOF in High-Risk Organizations . . . . . . . . . . . . . . . . 111
Corinne Bieder
Human and Organisational Factors: Fad or not Fad? . . . . . . . . . . . . . . 117
Jean-Christophe Le Coze
Breaking the Glass Ceiling: Levers to Promote the Influence
of Human and Organizational Factors in High-Risk Industries . . . . . . . 125
Benoit Journe
HOF: Adjusting the Rule-Based Safety/Managed Safety Balance
and Keeping Pace with a Changing Reality . . . . . . . . . . . . . . . . . . . . . . 133
Caroline Kamate
What Is the Place of Human
and Organisational Factors in Safety?
An Introduction

Claude Gilbert

Abstract It has been largely accepted, in academia as well as in business, that the
main vulnerabilities in industrial safety come from human and organisational factors.
Despite this consensus, it is still difficult for human and organisational factors (HOF
or OHF) to become a priority within companies. There are many reasons for this: HOF
are only included on the agenda in exceptional circumstances; the often-marginal
position of bodies in charge of HOF, which in addition, is still a fairly heterogenous
field of knowledge. Thus, the main question that seems to be raised is that of the place
that should be held by HOF, with two main options: either overtly affirming their
specific nature or being unobtrusively present in various ways in daily activities. In
turn, this leads us to ask ourselves about the relationship between the ordinary and
the exceptional within companies.

Keywords HOF · Safety · Ordinary daily life · Exceptional circumstances

The place of human and organisational factors (HOF) or organisational and human
factors (OHF) in safety, notably industrial safety, is rather paradoxical. On the one
hand, this question has been widely explored in the various fields of intellectual
output (by academics, experts, consultants, etc.) and recognised as being important
by stakeholders in safety (companies, supervisory bodies and agencies, insurance
companies, etc.). On the other hand, the question would appear to be the subject of
continued discussion and, although taken into account, would still not appear to be
a priority.
The result of this is a hiatus between the proclamations around HOF and their
veritable integration within companies and organisations responsible for managing
industrial risks. This book looks beyond the injunctions that are so commonly made
by academics and experts and seeks to better understand the reasons for and the
implications of such a situation and then, by doing so, offer suggestions for improving
it.

C. Gilbert (B)
CNRS/FonCSI, Grenoble, France
e-mail: Claude.Gilbert@univ-grenoble-alpes.fr

© The Author(s) 2020 1

B. Journé et al. (eds.), Human and Organisational Factors,
SpringerBriefs in Safety Management,
https://doi.org/10.1007/978-3-030-25639-5_1
2 C. Gilbert

1 What Place Is Given to HOF in Industrial Safety?

The way HOF are taken into account is the result of the obstacles encountered
when analysing events (incidents, near-misses, accidents), which were mainly, and
sometimes only, examined from a technical angle. In contemporary safety analyses,
it now seems to be taken for granted that the main vulnerabilities are related to HOF,
rather as if, in the various areas, we had reached the limit of the progress that could
be made from a technical point of view. Thus, any significant steps forward would
now have to be made at the human and at the organisational (or managerial) level.
On this point, there would appear to be a fairly broad consensus which allows the
engineering world to consider any residual imperfections in safety to be outside of
their scope of application. This allows the world of human and social sciences (HSS)
to acquire greater legitimacy for their work in this area.
However, the scope of HOF has not been clearly set out. The hesitation between
HOF and OHF, which is still commonplace, is related to ongoing debates about the
respective importance of “humans” and “organisations” in factors that put safety
at risk. Going beyond the set-piece and spontaneous approaches around “human
failings” and the progress made from the notion of “human error”, the challenge is in
fact to know just how far it is possible to scale the ladder of causes in order to identify
or allocate responsibilities. In other words, how can we avoid limiting analysis to the
behaviour of operators, or first-line management (as is still often the case)?
A number of disciplines have been drawn together to analyse HOF (ergonomics,
psychology, sociology of work, management sciences, sociology of organisations,
sociology of professions, etc.). Thus, knowledge capital and know-how exist,
although it would still be worthwhile questioning their constitution (such as, for
example, the role of human and organisational factors in the technical and scientific
choices within companies?). Or, to put it another way, is the way in which HOF are
limited closely related to the disciplines that have analysed them?
Nevertheless, HOF have acquired a status in the analysis of industrial safety, and
companies in charge of high-risk activities have been incited to examine this issue,
design specific safety actions and put in place the corresponding training. But this
rather indisputable general movement is facing a number of obstacles, partly due
to the fact that HOF are an “intermittent” priority within companies, according to
circumstances and contexts. As a result, it is mainly when serious incidents, accidents
or catastrophes occur that the debate around these factors is rekindled. Similarly, it
is mainly in these circumstances that researchers, experts and actors expressing their
concerns within companies are able to underline the importance of HOF.
What Is the Place of Human and Organisational Factors in Safety? 3

2 HOF in Industrial Safety: Still Trying to Find their

Place?

A first difficulty in the recognition of HOF comes from the fact that decision makers
only take them truly into account in exceptional circumstances. Which, of course,
makes regular and lasting inclusion of these questions a problem.
A second difficulty, which is related to the previous one, is that under normal
circumstances, the actors in charge of HOF often hold low-profile or even marginal
positions within companies. Of course, situations vary from one company to another,
but these actors usually operate within specific departments, hubs or agencies, away
from the major management teams. The consequence of this is that these structures,
in their various positions, can appear atypical compared to the organisation as a
whole, and refer to functions that need to be regularly justified and defended.
A third and final major difficulty encountered by HOF is that it is a very
diverse subject. HOFs cannot be described as being a uniform topic. Although some
approaches and schools are more developed than others, there is still broad hetero-
geneity in academic output as well as in its circulation via expert input and consul-
tancy work. Even if, within companies, specialist HOF structures can be identified
(see above), it is undeniable that questions about these factors are present in many
regular activities (concerning productive performance, motivation systems, produce
usage, health and safety, etc.). Thus, we find a fragmented set of references to HOF
in various company departments (production, human resources, safety, etc.). Some-
times, even the actors directly confronted with safety problems “do HOF without
knowing it” or, rather, without feeling the need to refer to any formal knowledge to
embark on actions in this area.
For all these reasons, the place that HOF and those who promote it can have within
companies is not automatic: it remains largely a work in progress. In many ways,
this may seem surprising given the now-recognised importance of HOF in safety
issues. We could even think that, in fact, it would not take much for HOF to be on
the agenda outside of exceptional circumstances, for the issue to be addressed within
companies, so that as a result of knowledge being tested on a large scale, doctrines
are established and then widely shared. And yet, this is not the case, the “means of
existence” of HOF remains a problem.

3 How to Make HOF “Exist”?

This question has progressively become more central in the discussions between
researchers and researcher-practitioners participating in this book. The question is
to decide what is the best strategy for ensuring that HOF become a lasting subject of
interest within companies.
4 C. Gilbert

A first option is to try to make HOF a priority for safety. This is a difficult but not
impossible goal to reach given the increasing attention paid to the risk of accidents,
notably major ones, and the sensitivity of certain key decision makers about this
subject. But this implies that those in charge of HOF would undertake very deliberate
actions with great consistency over time, while associating themselves closely with
the knowledge generators in this area. They would notably be raising the profile of
the structures they are leading high enough for them to be heard by deciders. This
option, which in many ways would appear justified, requires a lot of energy and its
success is heavily dependent on the circumstances.
Another more modest and more pragmatic option is based around the idea that
HOF are unlikely to be recognised as a priority by all decision makers anyway (other
than the group of those who were immediately convinced by them). In this approach,
the strategy would focus less on preaching their virtues and rather seek ways to allow
them to become part of the ordinary daily lives of companies. In other words, to keep
these concerns “alive” through a number of activities, without them being necessarily
linked to any risks. The downside of this being, of course, that the question of HOF
becomes less visible and less specific.
There is a debate around these two main options. The first and most obvious one
is risky, in the sense that it assumes that taking into account HOF means that there
is a real programme, of both knowledge and action, with true continuity over time.
This has the merit of coherency and makes it possible to envisage the drafting of a
doctrine based on specific knowledge and actors able to put them to the test in their
activities. The second option is risky in the sense that it can lead to a certain dispersal
or dilution in HOF knowledge. However, it has the merit of, discreetly and quietly,
being able to penetrate all levels of the company, at various moments.
This book discusses this difficulty in finding the right position. The position is
an essential question in order to determine how, today, industrial safety can be truly
enriched by the learnings from work on HOF. In some ways, this then leads us to
reflect on the relationship between the ordinary and the exceptional within companies
managing high risk activities.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter’s Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter’s Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Accounting for Differing Perspectives
and Values: The Rail Industry

Brendan Ryan

Abstract This chapter reflects on how researchers have worked in different ways
with industry in five research projects, investigating and implementing solutions for
problems related to human and organisational factors (HOF). Three observations are
presented on how improvements can be made in the management of HOF.

Keywords Railway · Organisational and inter-organisational relationships · Roles

of researchers and managers

1 Introduction

We often think that our own view is the best one, though there are many different
perspectives of work, the workplace and organisations. People in different roles,
levels of management, business functions or disciplines (e.g. safety, human factors,
human resources, management science) have interests in the management of human
and organisational factors (HOF).1 Safety is often explained as a priority, but other
factors (such as financial costs, production statistics, customer satisfaction) can be
priorities for some people. Attention can focus on control of obvious problems (e.g.
accidents during normal operations), though a narrow focus can allow vulnerability
to threats from less common issues, or those that are hard to solve, especially in
complex contexts, with involvement of multiple organisations.
This chapter is structured around three observations, more specifically, steps or
strategies that can be considered to improve the management of HOF. These have
been identified from reflection on a selection of railway research projects carried out
at the University of Nottingham. The observations are as follows: (i) that there is a

1 Human and organisational factors (HOF) as discussed in this chapter are considered to be syn-

onymous with ergonomics and human factors (E/HF), as defined by the IEA—https://www.iea.cc/
whats/.

B. Ryan (B)
University of Nottingham, Nottingham, UK
e-mail: Brendan.Ryan@nottingham.ac.uk

© The Author(s) 2020 5

B. Journé et al. (eds.), Human and Organisational Factors,
SpringerBriefs in Safety Management,
https://doi.org/10.1007/978-3-030-25639-5_2
6 B. Ryan

lack of clarity on how HOF should be managed alongside other business objectives;
(ii) that there is a need to look again at the respective roles of researchers and managers
in research and practice in HOF; (iii) that HOF can be viewed as a method or analysis
tool to understand the reality of people at work or interacting with systems.

2 The Research Studies

Overviews of the five projects that have informed the observations on the management
of HOF are given in the Tables 2.1, 2.2, 2.3, 2.4 and 2.5.

Table 2.1 Overview of research project 1

What do people do on the railway?
Part A The first piece of work supported the infrastructure manager in understanding their
processes for rail engineering work [23], including observing engineering work sites,
interviews with staff in various roles, and group meetings to develop, display and
discuss typical working scenarios (e.g. [18]). This produced an in-depth understanding
of work functions and risks, descriptions of contexts and human factors affecting
performance of functions. Even though we identified thematic areas and
recommended programmes of work to tackle these, we were not always successful in
engaging with the client and there was a perception that this was not solving the
problems quickly enough
Part B The second study was carried out for the European Union Agency for Railways
(ERA), who wanted to overcome perceived bias in the industry towards technical
standards [14]. This focused on what people do in a wider range of frontline railway
roles (driving, rail control, station dispatch, rolling stock maintenance, infrastructure
engineering). This was important in identifying: different types of organisational and
individual goals; what people need to do (i.e. the human functions) in various
contexts; and the safety relevant activities associated with these human functions

Table 2.2 Overview of research project 2

Improving safety performance in the construction supply chain
Context In road/rail transport construction, projects are usually conducted by multiple
organisations. Evaluating the success of interventions in this type of dynamic,
multi-organisational context is not straightforward. Consequently, effective
evaluation studies are often not carried out
Part A 21 interviews across the supply chain explored factors affecting leadership in
multi-organisation projects [21]. 26 different examples of safety leadership have
been identified, aligned with nine areas from literature (e.g. demonstrating safety as a
top priority, enabling safety reporting)
Part B The effectiveness of a suite of leadership interventions is being explored in a
longitudinal study in six large engineering projects. Progress (what is being
implemented and how) is being tracked using theory of change methodology [7] to
make sense of the wide-ranging data
Accounting for Differing Perspectives and Values … 7

Table 2.3 Overview of research project 3

What do business leaders want?
Context It is not known whether industry decision-makers talk naturally about safety
concepts from literature (e.g. top down/bottom up safety approaches, how different
forms of risk can be addressed, the nature of communications, and resilience) or how
these are useful to managers
Part A 25 in-depth interviews were carried out with rail industry leaders [12], to determine
what senior executives/managers really want in relation to safety and business
performance. The interviews provide insight to what leaders think about trade-offs
involving safety, organisational structure, the desire for improvement and the
challenges in implementing changes across the industry
Part B Two business change programmes are also being tracked over an extended period.
Research activities (interviews with programme managers, review of project
documents and meetings, surveys and observational work with frontline staff) are
collecting broad ranging data on the programmes and safety and business
performance [11]. Emerging findings indicate that industry leaders have a good
awareness of problems with implementation of change programmes

Table 2.4 Overview of research project 4

Railway suicide—A continuing threat to safety and performance on the railway
Context There are many known prevention methods for railway suicide, but there have been
few efforts to evaluate their effectiveness [16]
Part A A collaborative project between academic researchers and industry [16], developed
and implemented a method to identify the most promising safety interventions for
field testing
Part B One of the promising fencing interventions has been evaluated over an extended
period of time [25]. Detailed, descriptive data are being collected on the extent of
implementation and the impacts of the safety intervention. Understanding the
context into which the intervention is placed has been critical
Part C A simple evaluation framework has been developed in conjunction with the industry
to support the collection of better evidence on the effectiveness of various types of
safety prevention measures [17]. In spite of engagement with the industry throughout
the development process, difficulties were experienced when piloting the framework
with industry partners. Very simple barriers hindered progress (e.g. lack of time, not
knowing where to start collecting data)

Table 2.5 Overview of research project 5

Developing new lighting products for stations
Context This is an innovation project, led by an industry partner, with researchers working
closely with industry to provide the underpinning theory and research support. The
project considers: What characteristics or qualities of lighting (e.g. movement,
intensity, colour) could influence behaviour (wayfinding and crowd movement)?
Part A Review of state-of-the-art in lighting and stakeholder engagement to support the
specification and design of new lighting products for stations
Part B Evaluation of the effectiveness of new products (using human factors methods and
new sensing technologies)
8 B. Ryan

3 Observations on the Management of HOF

The projects had different aims and contexts, though some overlap in their focus.
There is commonality in the methods, but also differences in their application. The
three observations introduced initially in Sect. 1, are expanded below.

3.1 The Lack of Clarity on How HOF Should Be Managed

Alongside Other Business Objectives

There are multiple goals (organisational and personal—Project 1, [14]) and different
objectives that can take precedence in different situations and contexts [23]. The
extent to which objectives such as safety and business performance can or should
compete is not clear. The interviews with business leaders (Project 3) collected
views on their priorities. It is too simplistic to view these as two-way trade-offs
(e.g. cost vs. safety). In practice, there are likely to be inter-changeable priorities,
from amongst two or more objectives. The importance of context in trade-offs needs
to be recognised.
A second consideration is that many commercial ventures are conducted by an
array of organisations for a defined period. There are opportunities for leadership
interventions and supply chain management to influence processes and organisational
practices along the supply chain (Project 2), but to date there has been little research
in this area. Units in the supply chain should not be viewed as static or homogenous
entities. There will be pockets of culture in organisations and variation in behaviours
within an organisation, due to the relationships and influences in multi-organisational
projects.
Survivability can be considered at the heart of organisational decision-making in
many circumstances. Supply chain logic indicates that organisational transition can
be expected over time from survival to growth [5]. As HOF scientists and practi-
tioners, it is important to support transitioning from a goal of survivability of the
organisation to one of fulfilment of organisational needs. This can include continued
efforts to raise the prominence of safety and related factors and ensure that these
receive appropriate consideration alongside other objectives.
It is clear that scientists need to work with industry to be able to understand
the nature of the business trade-offs as a first step in determining organisational
priorities in a transitory multi-organisational context. This could include providing
the tools to specify and work with data from industry and providing descriptions of the
contexts and situations in which these trade-offs can occur. Doing this within a truly
collaborative environment is desirable, though this is rarely achieved in practice. The
respective roles of two of the stakeholders (researchers and users of HOF research,
e.g. managers, practitioners, [3]) are considered in more detail below.
Accounting for Differing Perspectives and Values … 9

3.2 Looking Again at the Roles of the Researcher

and Manager

In our projects, there were differences in the roles of the researchers and how they
interacted with industry, potentially impacting on the success of the project. Imple-
mentation of a solution from academic or industry-based research is not a straight-
forward exercise. We have learned by experience about what can help build and
inhibit collaboration in projects, such as differences in the motivations, experience,
knowledge and expectations of ourselves and the other stakeholders.
In Project 1 we worked closely with industry over extended periods in the early,
data gathering phase, but we could not maintain this type of collaboration through
all of the research and implementation phases. We encountered similar problems
in sustaining engagement in Project 4. What may appear to be good fortune (an
insider researcher, [1]) facilitated access to interviews with senior decision-makers in
Project 3, identifying different perspectives within and between organisations. Here
the role of the researcher was critical. There are advantages to the manager-researcher
(insider researcher) role, such as pre-understanding of the organisation and ability
to manage organisational politics [1], often achieving results that are not possible
from an outsider [4]. There are also challenges, where the manager–researcher has
to “reframe their understanding” of the organisation, overcome problems associated
with having a dual role [1] and various ethical issues [4].
Considering how to improve collaboration between researchers and operational
staff is not a new question. Churchman and Schainblatt [2] reported that science and
management need to know each other better. However, achieving “mutual under-
standing” [2], which is really at the heart of this problem, is not a simple endeavour.
One explanation for this is that managers and scientists are not open about their real
methods (e.g. how managers make decisions, or how researchers work creatively,
[2]).
The researcher/practitioner gap has been explored in the discipline of
ergonomics/human factors [19], pointing out problems of accessibility and usability
of some academic methods. There has been reluctance to “give away” ergonomics
methods to industry/novices [20], because of a required level of knowledge/expertise
for the reliable and valid application of the methods. These findings on the utility of
methods are important, but the interface between these groups needs closer scrutiny,
to develop better collaborative work programmes. Reid et al. [15] have suggested that
there is a bi-directional relationship, considering how to move ergonomics concepts
from research to practice and ergonomics problems from practice to research. This
is influenced by researchers (who worry about conducting “good research” for var-
ious reasons) and practitioners (who may not appreciate the value of well-designed
research and feel that researchers’ interests may not align with their own).
Part of the solution to these problems is about developing better understanding of
the different perspectives of those involved [15]. Whereas scientists attempt to form
objective conclusions in a given set of circumstances (and at the risk of not being able
to be conclusive), the manager in industry needs to make a practical decision, often in
10 B. Ryan

spite of uncertainty in the evidence [9]. Neumann et al. [10] have explained how gen-
eralised knowledge of science is insufficient for successful change and needs to be
absorbed and combined with the existing experienced based knowledge from practi-
tioners in organisations. Action research [10] or participatory ergonomics to embed
human factors in organisations [24] are promoted as ways forward for researchers
to work collaboratively with stakeholders. I have very much appreciated the analogy
provided by Francois Daniellou, of the need for “researchers with dirty hands”—
placing researchers on the beach with the people, rather than viewing the people from
the clifftop.2 In this analogy, researchers also need the ability to take the people to
another viewpoint (e.g. mountain top). Elements of this close working with industry
are evident within our projects. In Project 5, an industry partner leads the project and
the motivation comes from the desire to market products. The industry is open to
expertise of the researcher and potential value of scientific input. Researchers ben-
efit from the commercial focus and clarity in priorities of the industry partners, but
must be willing to be flexible and compromise, without sacrificing rigour, to reach a
mutually agreeable solution.
A second set of considerations relates to the differing capabilities and limitations
within these groups [3]. There are different job demands and needs across indus-
tries, and different knowledge, experience, backgrounds and education, within and
between researchers and practitioners. Whilst it is right to consider the differences
between research and practice, our experience indicates that there are also within
group differences. As such, all partners in collaborations will lie somewhere on a
continuum from pure research to pure application. We should not expect to unify or
reconcile these differences and influences and the diversity has to be considered as
an opportunity. We all need to reflect and be open about our weaknesses, in addition
to promoting our strengths, and be receptive to new ideas and viewpoints [22] in
order to find practical ways forward.

3.3 Viewing HOF as a Method or Analysis Tool

to Understand the Reality of People at Work
or Interacting with Systems

HOF should not just be viewed as a body of knowledge. The research projects
have valued the description of work and contexts (“what people do”), usually as a
part of achieving other project objectives (e.g. safety analysis or implementing and
evaluating safety interventions). This description has placed an emphasis on “work as
done” [8] and taken account of the wide-ranging stakeholders/organisations involved
in running, maintaining or using the operational railway, and “listening to the people”

2 Residential seminar held in January 2018 in Royaumont, France, which has led to this book
(Editor’s note).
Accounting for Differing Perspectives and Values … 11

at the front line to support better decision-making. It was heartening to hear that this
was also recognised by the managers of organisations (“people matter more than
structure”, Project 3).
Our interactions with industry have also been designed to give a new view (for
example using agent-based simulation, [13]), showing possibilities of what could
happen. Our outputs are often in the form of simple, descriptive accounts, presenting
findings from field studies in text, tables and figures. Findings can be represented
in new ways, not necessarily collecting new data, but collating and compiling what
already exists. This needs effort and time to do what others have not, looking again at
the evidence, to make new connections in the data and help others to see what we can
see. One of the challenges has been how to collate and analyse the findings in ways
that are useful to both the academic and industry communities. There is a case to be
made for developing better metrics and measures for the study of HOF and these are
often preferred by managers and engineers. However, the value of qualitative data in
research and practice is evident [6].
There are circumstances when application of our research methods needs time.
For example, the evaluation studies (Projects 2, 4) and longitudinal studies (Projects
2, 3) benefit from the extended nature of these (e.g. part time Ph.D. process in
some cases) and ability to track projects over lengthy time periods. This is exposing
how change in business policy and practices can impact on the implementation and
success of safety programmes. However, there have been situations where we have
not been able to respond to the required pace of change (Project 1). We have also
encountered situations where the industry has recognised how they have underesti-
mated constraints on the speed or implications of change (Project 3). This introduces
interesting questions about the existing approaches of researchers and industry staff
in programmes of this nature.

4 Concluding Thoughts

The three observations offer directions for future research and practice. All work
needs to operate within constraints (e.g. costs, resources, time available). However,
we need to continue to promote our values and retain our disciplinary identities,
especially around the importance of considering people, improving safety, life and
health, otherwise we will be pushed further along routes that we do not want to go.
The way of doing this is not clear, though success is likely to be found in identifying
better ways to work together (especially researchers and managers), considering
all business functions and all phases of exploring problems and implementing and
evaluating solutions. Developing a better understanding of the different perspectives
and capabilities/limitations of our partners is essential.
HOF scientists and practitioners are a body of many disciplines and backgrounds
and this diversity has to be a positive thing. We need to look more carefully at the
nature of our engagement and how we seek to collaborate or embed HOF in our
workplaces. There have been some compelling arguments for better measures and
12 B. Ryan

metrics. However, we must not lose focus on collecting and articulating details of the
context (i.e. looking harder, looking differently or showing others what we can see)
and developing the qualitative examples and case studies that can be used in timely
and practical ways by industry to start working on their immediate needs.

Acknowledgements I would like to express my thanks to all of the researchers/co-authors of the

listed projects. I would also like to acknowledge and thank the many staff in industry that have
supported, challenged and contributed to these projects over recent years. I also recognise the
contributors at the FonCSI seminar who offered inspirational critique on the work and especially
Hervé Laroche, who has provided valuable comments and input throughout the development of this
chapter.

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Safety Leadership and Human
and Organisational Factors
(HOF)—Where Do We Go from Here?

Kathryn J. Mearns

Abstract Investigations into major disasters in safety critical industries consistently

reveal failings in safety leadership, including poor decision-making and lack of effec-
tive challenge and inadequate management oversight and scrutiny of safety, as major
contributory factors (e.g. Texas City, 2005; Royal Air Force Nimrod, 2006). More
recently, a lack of regulatory oversight has also been implicated in disasters such
as Deepwater Horizon [2] and Fukushima Daiichi [17]. There is also evidence of
an inability to apply the lessons learned from major accidents, whether they have
occurred in the same or other major accident hazard industries. This chapter consid-
ers these issues and the potential interplay between actors at the more senior levels
of organisations and the regulators of the industries involved. The chapter also con-
siders the role of safety culture assessments as a means of identifying the human
and organisational factors that are either undermining or enhancing safety within the
organisation and the need for senior leadership having the right mind-set to take due
cognisance of this intelligence to implement measures that improve safety. Strong
and competent regulators should support this approach.

Keywords Public inquiries · Leadership · Safety culture · Regulators

The organizational causes of this disaster are deeply rooted in the histories and cultures of the
offshore oil and gas industry and the governance provided by the associated public regulatory
agencies. While this particular disaster involves a particular group of organizations, the roots
of the disaster transcend this group of organizations. This disaster involves an international
industry and its governance ([2], Investigation of the Macondo Well Blowout Disaster, p. 9).

K. J. Mearns (B)
Wood PLC, Aberdeen, UK
e-mail: k.j.mearns@gmail.com

© The Author(s) 2020 15

B. Journé et al. (eds.), Human and Organisational Factors,
SpringerBriefs in Safety Management,
https://doi.org/10.1007/978-3-030-25639-5_3
16 K. J. Mearns

1 Introduction

The quote given at the start of this chapter highlights the human, organisational, regu-
latory and ‘cultural’ shortcomings that have been consistently identified as underlying
causes of major accidents in safety critical industries, irrespective of technology or
regulatory regime. The list includes Bhopal, Herald of Free Enterprise, Three Mile
Island, Chernobyl, Challenger, Columbia, Texas City, Royal Air Force (RAF) Nim-
rod, Deepwater Horizon and Fukushima Daiichi. The common failings identified
from Public Inquiries and investigations into these major disasters, include:
• Ineffective leadership;
• Poor operational attitudes and behaviour;
• Poor decision-making and lack of effective challenge;
• Lack of training and competence;
• Inadequate management oversight and scrutiny of safety;
• Failure to apply safety lessons learned both from within and outside the
organisation and/or industry.
The investigations invariably identify failings at the organisational level (i.e. senior
leadership), particularly regarding decisions around the production/safety trade-off.
For example, in his report into the loss of the RAF Nimrod, Charles Haddon-Cave [8],
referred to ‘A Failure of Culture, Leadership and Priorities’ and provides damning
criticism of Britain’s largest defense and arms company:
The regrettable conduct of some of BAE Systems’ managers1 suggests BAE Systems has
failed to implement an adequate or effective culture, committed to safety and ethical conduct.
The responsibility for this must lie with the leadership of the company (p. 261).

These investigations into major disasters also consistently call for ‘lessons to be
learned’ but it would appear that either these lessons are quickly forgotten or there is
a failure to implement the necessary actions arising from these lessons. For example,
the Deepwater Horizon Study Group [2] reports that:
At the time of the Macondo blowout, BP’s corporate culture remained one that was embedded
in risk-taking and cost-cutting – it was like that in 2005 (Texas City), in 2006 (Alaska North
Slope Spill), and in 2010 (“The Spill”), (p. 5).

BP clearly failed to implement the lessons learned from its previous disasters, as
did NASA in the case of Challenger [25] and Columbia [24].
Apart from the major accident investigation findings, the research evidence shows
strong support for the relationship between effective safety leadership at all manage-
ment levels (including executives), a healthy safety culture and good safety perfor-
mance (for reviews see [9, 10]). There is also an increasing focus on the role of
regulators and their contribution to the aetiology of these disasters and a call for
more competent and challenging regulators for the industries affected, i.e. offshore
oil and gas (Deepwater Horizon) and nuclear industries (Fukushima Daiichi).

1 BAE Systems is a British aerospace and defence large industrial group.

Safety Leadership and Human and Organisational Factors (HOF) … 17

The objective of this chapter is not to provide a new theory or share new ideas
about how to improve human and organisational factors (HOF) in safety. On the
contrary, the chapter explores the evidence that we already have to demonstrate that
a focus on HOF is required to improve safety and how that focus can be achieved.
As a result, this chapter covers three themes:
1. The role that leadership plays in developing and sustaining the safety culture of
their organisations;
2. The importance of regular assessment of and attention to safety culture to identify
the state of human and organisational factors that influence safety;
3. The role of a competent regulator in the oversight of leadership and man-
agement for safety and ensuring that adequate attention is paid to the find-
ings of safety culture assessments to inform senior management leadership and
decision-making.

2 The Role of Leadership in Developing and Sustaining

Safety Culture

Perhaps there is no clear-cut “evidence” that someone in BP or in the other organizations in

the Macondo well project made a conscious decision to put costs before safety; nevertheless,
that misses the point. It is the underlying “unconscious mind” that governs the actions of
an organization and its personnel. Cultural influences that permeate an organization and
an industry and manifest in actions that can either promote and nurture a high reliability
organization with high reliability systems, or actions reflective of complacency, excessive
risk-taking, and a loss of situational awareness [2, pp. 5–6].

A wealth of research data has been generated on how leadership at all levels of
an organisation can influence the safety performance of front-line operations. This
includes research on the role of supervisors [18, 27], middle management [15, 19]
and senior management [5, 20]. The role of senior management commitment to
safety seems to be particularly important, in that their perceived attitudes, values and
actions appear to be one of the most cited components of safety climate and safety
culture research [4].

3 The Role of Safety Climate and Safety Culture

Assessments

Senior managers set the agenda for safety in terms of their vision, values and strategy
for safety, however this can only work if it is accepted, adopted and implemented
throughout the whole organisation. Acquiring the right sort of ‘safety intelligence’
from the bottom up [7] is important. Managers at all levels of an organisation must
18 K. J. Mearns

be receptive to ‘bad news’ as well as ‘good news’ and they must be attentive to
the ‘signals’ that indicate all is not well within their organisation and be willing to
take action where necessary. A properly developed and implemented safety culture
assessment provides a wealth of safety intelligence for managers to act upon.
Safety climate and culture assessments provide an opportunity for senior man-
agers to gain an understanding of how the safety management systems (SMSs) and
technical safety interventions as conceived and constructed are actually implemented
in the organisation. There is often a mismatch between ‘work as imagined’ versus
‘work as done’ and between ‘work as prescribed’ versus ‘work as disclosed’ [3, 12].
Safety climate/culture assessments can assist in identifying where these mismatches
lie and if properly conducted can identify the interventions that can close the gaps.

4 The Role of the Regulator

It is important for all employers and employees, to be aware of and fully understand,
their duties under legal frameworks for health and safety. Within the UK this is
enshrined in the Health and Safety at Work, etc. Act (1974) with other legislation
arising from it, e.g. Management of Health and Safety at Work Regulations (1999).
More recently, the UK’s Corporate Manslaughter and Homicide Act 2007, clari-
fies the criminal liabilities of companies where failures in the management of health
and safety result in a fatality. Prosecutions are of the corporate body itself, how-
ever, directors, board members and others can still be prosecuted for separate health
and safety offences. One of the challenges of the act is identifying ‘the controlling
mind’, i.e. the person whose thoughts and actions control the company’s affairs. This
is particularly difficult in large companies where there are complex management
structures and health and safety is often delegated to more junior managers who
are not ‘controlling minds’. Prosecutions therefore tend to be more successful under
breaches of the Health and Safety at Work etc. Act 1974, although there have also
been successful prosecutions under the Corporate Manslaughter and Homicide Act
2007 (e.g. the Lyme Bay tragedy).
Before an organisation ends up in court for serious breaches of health and safety
legislation, government regulators have the power to shut down operations if they
have evidence that the legislation is not being complied with. This is the sort of
independent challenge that senior managers usually respect and pay attention to.
It is the ultimate challenge, with severe consequences for the profitability of the
organisation. If there is a fatality or major accident, the imposition of fines will
hurt the company’s ‘bottom line’; the publicity and its consequences will hurt the
company’s ‘reputation’. These are matters very close to any senior manager’s heart.
Furthermore, apart from the consequences for the organisation, there can also be
consequences for the individual with many senior managers reporting they never
want to be in a position to tell family members that a loved one will not be coming
home following a fatal accident. Such experiences tend to develop managers who
have a focus on health and safety. Fortunately, major accidents are comparatively
Safety Leadership and Human and Organisational Factors (HOF) … 19

rare events as are fatal accidents at work, so the capacity for this type of emotional
learning is very limited and it could obviously never be endorsed.
In making decisions to shut down company operations, the regulator has to be
‘proportionate’ in its assessment with due reference to the concept of ‘as low as
reasonably practicable’ (ALARP). This means that the regulator has to assess whether
the measures taken are grossly disproportionate in relation to mitigating those risks.
This trade-off has to be considered in the context of the law and what is acceptable
from a risk management and safety perspective. ALARP serves society by placing a
heavy weight on the precautionary principle in a way that controls risks for human
beings and the environment. The practical procedures for implementing ALARP are
mainly found in engineering judgements and codes but also in traditional cost-benefit
analysis (CBA). According to Aven and Abrahamsen [1], CBA ignores uncertainties
because it is based on attitudes to risk and uncertainty, which are ‘risk neutral’
and therefore in conflict with the precautionary principle and ALARP. French et al.
[6] also identify shortcomings with CBA and advocate the implementation of multi-
attribute utility theory (MAUT) to address the perceptions of all stakeholder groups in
order to facilitate constructive discussion. They argue that being explicitly subjective
provides an open, auditable and clear analysis, which contrasts with the ‘illusory’
objectivity of CBA. The findings from safety climate/culture assessments reflect the
perceived/subjective risks of stakeholders on the front-line and throughout the wider
organisation and could be used in MAUT as another tool to add to the organisation’s
and the regulator’s armoury to assess risks and support decision-making.
If senior management are so critical to developing and sustaining an organisation’s
safety culture and are instrumental in assessing and managing the organisation’s
health and safety risks, how can we determine whether they display the necessary
leadership qualities, decision-making processes, capacity to manage organisational
change and learn from previous accidents?

5 A Regulatory Perspective on Leadership

and Management for Safety (L&M FS)

The International Atomic Energy Agency (IAEA) has developed guidance for man-
agers and regulators to assess L&MfS [14]. The UK Office for Nuclear Regula-
tion (ONR) provides an example of how this guidance has been implemented. The
ONR regulates the UK nuclear industry using a set of Safety Assessment Principals
(SAPs) that have to be complied with before nuclear organisations in the UK can
be granted a licence to operate [16]. Four Management System (MS) SAPs are key:
MS.1-Leadership; MS.2-Capable Organisation; MS.3 Decision Making and MS.4
Learning. Each SAP consists of a number of components, e.g. leadership attributes;
control of organisational change; decision-making processes and learning culture,
etc. These four ONR SAPs and their components also make clear links to safety cul-
ture. The ONR uses these SAPs and associated guidance to conduct L&MfS reviews
20 K. J. Mearns

of duty holders as and when required. The managers of nuclear organisations have to
demonstrate their competence in these areas as part of the Safety Case and Periodic
Reviews of Safety (PRSs) to ensure that the company is still fit to operate.
Originally designed as a set of themes for discussions at the executive level of the
organisation, the L&MfS reviews allow the regulator to challenge senior managers
on their leadership, their organisational capability, e.g. knowledge management and
succession planning, decision-making, and learning ability, i.e. do they learn from
incidents and implement the necessary changes to prevent such an incident occurring
again. This can consist of a review of an organisation’s safety management system
(SMS) and a series of interviews and/or focus groups with a cross-section of the
organisation’s workforce, including senior management. Reviews of safety culture
assessments, incident investigations and operating experience reports can also be
conducted. These help to demonstrate the extent to which the ‘work as imagined’
matches ‘work as done’ and ‘work as prescribed’ matches the ‘work as disclosed’.
Other regulators, e.g. the Health and Safety Executive [11] and industry bodies e.g.
International Association of Oil and Gas Producers [13] have issued safety leadership
guidance. Clear guidance and strong regulatory scrutiny can provide the necessary
incentive for organisational leaders and senior managers to focus on improving their
own decision-making processes and behaviour and appreciate the central role they
play in developing and reinforcing the safety culture within the organisations they
are responsible and accountable for.

6 Conclusions

Human, organisational, regulatory and ‘cultural’ shortcomings have been consis-

tently identified as underlying causes of major accidents in safety critical industries,
irrespective of technology or regulatory regime. Despite this wealth of data, there
is also evidence of an inability to apply the lessons learned from major accidents,
whether in the same or other industries. The challenges faced by the complex (and
often complicated) organisations that run safety critical industries, should not be
underestimated, however the evidence from public inquiries and investigations into
major accidents indicate that demonstrations of stronger regulatory oversight and
an engaged and accountable senior management are worthy of consideration. Fur-
thermore, decades of research has shown that no matter what the industry, the same
issues emerge from safety culture/climate assessments, i.e. perceived lack of senior
management commitment to safety; inadequate communication (too much of the
wrong sort or too little of the right sort); inadequate procedures (badly written or
out-of-date); inability to ‘speak up’/fear of ‘challenging’ about safety and lack of
organisational learning.
On providing senior managers with feedback from their safety culture/climate
surveys, there is often disbelief that the workforce views the organisation in this way.
Indeed, a common finding from these surveys is that senior managers perceive the
safety culture as much more positive than their workforces. As a result, there can be a
Safety Leadership and Human and Organisational Factors (HOF) … 21

reluctance to do anything about the findings. Action plans are developed but evidence
of serious implementation is not necessarily forthcoming. Senior managers are very
good at talking about the importance of safety but seem less able to address the human
and organisational issues that undermine safety. They also often seem to be unable to
implement the lessons learned from public inquiries into major accidents, despite the
findings from these inquiries being widely available. What could be the reasons for
this? Is it because interventions arising from safety culture/climate findings and the
findings of public inquiries into major accidents are too costly? Or is there an attitude
that this could never happen here? Or do senior managers simply not understand how
HOF can influence the safety performance of an organisation? Given the decades of
evidence to the contrary, these reasons are not tenable and yet, no other reasons come
to mind except that making profits and keeping the shareholders happy are paramount
and trump all other considerations. To some extent, this is understandable. Safety
cannot be sustained if the company is not making money to invest in improvements.
Fortunately, major accidents are rare events and therefore the attitude ‘it cannot
happen here’, may be justified in the minds of senior managers, however, as Trevor
Kletz is famously reported as saying, ‘If you think safety is expensive, try having an
accident’.
In order to make progress, safety critical industries require well-resourced and
highly competent regulators who are capable of making strong and legitimate chal-
lenges to senior managers on their safety leadership qualities, backed up by enforce-
ment action. Unfortunately, there has been a trend in recent years towards de-
regulation, often with drastic consequences, e.g. the 2008 financial crash, and con-
tinuing debates about whether or not the internet should be regulated. The lack of
adequate regulation was also implicated in the Macondo (Deepwater Horizon) and
Fukushima Daiichi disasters and a recent UK parliamentary inquiry into the col-
lapse of the Carillion organisation, revealed evidence of weak financial and pensions
regulators.
The way forward is for regulators and senior managers to work together to achieve
safer and more resilient working environments in safety critical industries. However,
we must not forget the workforce’s involvement in this process and this is where safety
climate and culture assessments play a role. These assessments provide good safety
information to senior managers but only if properly developed and implemented
by competent people with an understanding of the validity and reliability of their
measures. Depending on the level of the analysis required, these assessments cover
themes such as the lack of cross-communication, which prevents reciprocity, the
validity of work systems and procedures, i.e. work as imagined and prescribed in the
SMS does not reflect work as disclosed and done on the front-line, and the lack of
leadership visibility to reinforce the norms and values that define the organisation.
Leaders need to learn about and understand these issues by actively listening as well as
observing because, as many public inquiries into major accidents have demonstrated,
these are the conditions that could show that their organisation is drifting towards
failure [3].
Woods [26] makes reference to the 4Is (independent, involved, informative and
informed) and the need for an independent challenge of senior managers’ decision
22 K. J. Mearns

making in their trade-offs between production and safety. Competent regulators can
provide that independent and informed challenge along with the insights provided
by properly developed and implemented safety culture/climate assessments, which
ensures the involvement of the workforce in providing the information for manage-
ment to act upon. These assessments can be used in the implementation of MAUT to
address the perceptions of all stakeholder groups, facilitate constructive discussion
and support the decision-making of senior managers and regulators.

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Perform. Eng. 3(3), 345–353 (2007)
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Blowout. Center for Catastrophic Risk Management, Mar 2011
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(2017), pp. 8–9
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Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
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the copyright holder.
Considering Human and Organizational
Factors in Risk Industries
What Should We Expect? How Do We Manage this
Subject?

Christian Neveu, Valérie Lagrange, Philippe Noël and Nicolas Herchin

Abstract The industrial partners of the Foundation for an industrial safety culture
(FonCSI) agree on the importance of considering human and organizational factors
(HOF) for safety. Nevertheless, many questions remain regarding how to address this
issue in industrial organizations. In this short chapter, HOF experts of companies
supporting FonCSI and representing various industrial sectors (energy, transports,
oil & gas) expose their viewpoint on HOF goals, strategies, approaches, methods
and tools.

Keywords Risk management · HOF approach · Safety strategy

1 HOF Approach: Features and Benefits

Since the creation of the risk industries, different kinds of approaches have been
developed in order to avoid accidents: although at first purely technical, since the
1980s these approaches have taken into account human and organizational factors
(HOF) (see Fig. 1).
Today, the lessons learned from each of these historical steps show that risk
industries need to implement a HOF approach with particular features:
• an integrated approach, distinct from the “man or machine” dichotomy;

C. Neveu (B)
SNCF, Paris-Saint-Denis, France
e-mail: christian.neveu@laposte.net
V. Lagrange
EDF, Paris-Saint-Denis, France
P. Noël
TOTAL, Paris-La Défense, France
N. Herchin
GRTgaz, Paris-Saint-Denis, France

© The Author(s) 2020 25

B. Journé et al. (eds.), Human and Organisational Factors,
SpringerBriefs in Safety Management,
https://doi.org/10.1007/978-3-030-25639-5_4
26 C. Neveu et al.

Fig. 1 Evolution of risk management approaches (adapted from [1, 2])

• a realistic vision of the ‘human’, as a factor of reliability with limits, whose role
must be facilitated by:
– reducing the situations favourable to errors and failures,
– reinforcing the capacity and the means to manage the diversity and the
unforeseen nature of operational situations;
• a “field” approach, based on the interactions between technical systems, humans
and organization in real situations.
For these reasons, FonCSI’s definition of HOF seems to be particularly pertinent:
“identify and set up the conditions which favour a positive contribution of operators
and collectives in safety”.
Furthermore, with this kind of HOF approach, even if it focuses on safety and
security performances, it actually contributes more globally to the quality of operation
as a whole and is positive for all performances.
Following these historical steps, such programs initially dealt with human factors
in incident investigation, ergonomics in the workplace and human factors in design.
Then, the influences of sociology and psychology led to research to understand prob-
lems in organizations that resulted in incidents. The issues of decision making, safety
culture, management of change, cooperation, are now also taken into consideration.
They concern everybody, from the operator to the senior vice-president and all man-
agers; they concern corrective actions after incidents, but are increasingly focused
on preventive actions, which form part of the initial training for individuals and of
continuous improvement action plans for units (Fig. 2).
Considering Human and Organizational Factors in Risk Industries 27

Fig. 2 Evolution of the attention given to the dimensions of safety management at EDF (adapted,
with permission, from an internal EDF document)

2 How Do We Implement and Manage HOF Approaches?

Through the historical development of HOF approaches in risk industries—aero-

nautics, railways, nuclear, oil & gas… and now in the health sector, an “ideal”
implementation has clearly emerged:
• It would begin by creating a team of HOF Experts1 at the corporate level, in order
to define a roadmap (aims and strategy for the next 3–4 years, based on a diagnosis)
addressed to the top management and to suggest methods and tools for supporting
the HOF dynamics.
• Then, it needs to benefit from relays in the organization, by putting in place HOF
consultants2 or HOF correspondents3 at local levels or intermediate levels in
charge of developing action plans: HOF training, field analysis, support depart-
ments and local managers for main actions such as implementing HOF methods
and tools such as incident investigation, human performance, operational decision
making … (Fig. 3).

1 Expert means Ph.D. or at least 3rd cycle graduate in ergonomics, psychology, or sociology, with
a position in the organization in order to support the top management in HOF domain.
2 Consultant means a 4–5 years mission carried out by a person who may have an operational

background but has received additional high-level training in HOF.

3 Correspondent means a person well trained on one specific HOF method (short training), identified

as a referent inside her/his department.

28 C. Neveu et al.

Fig. 3 Content of the SNCF HOF project

Depending on the current challenges of the company and its maturity level in this area,
the implementation of the HOF approach could take various forms. Nevertheless,
three invariants need to be respected:
• Whatever the methods used by companies, the effectiveness of the program relies
on an in-depth understanding of functions and risks, discovering the real human
activity in a job or a task. It must be focused on what people do, how safety is
produced, what can go wrong and what can be done to prevent this.
• In each sector, the HOF approach must be controlled: by the safety management
system (SMS), with a clear ambition, action plan, measure of performance and
efficiency.
• The basis of HOF dynamics requires competencies, from
experts/consultants/correspondents, but also from each employee, including
managers. Everybody has to acquire HOF skills—knowledge and know-how—in
order to develop a safety culture and good practices.

3 Difficulties and Opportunities

The first key problem to achieving the objectives of HOF programs observed in
companies is the turnover of staff in the management line, and specifically at the
senior management level. The senior management of the entity must be involved in
the program as the main sponsor. This is a key condition to ensuring that it will be
taken to its conclusion even though the environment may change. However, each
Considering Human and Organizational Factors in Risk Industries 29

time the senior management changes, the program runs the risk of being stopped or
reinitialized, with a period of questioning. Sometimes the turnover rate is so high
that the outcomes of such program are lost.
Another aspect is the continuous moving environment. The worldwide or domestic
market can quickly change because of unforeseen circumstances; this could result in
a decision being made to change the organization, the methods implemented and/or
the tools. Because HOF programs need time to achieve their results, in a moving
environment they are exposed to be defined again in order to be well-adapted.
It probably means that HOF are not really integrated enough in safety management
processes. They depend to a large extent on the conviction of individuals, not of the
whole organization.
The second key problem observed on how HOF programs work is the impact
of the regulator which has not necessarily reached a high level of maturity in the
HOF approach (e.g. looking for responsibility versus discovering the work situation).
Based on how the observed reaction of the regulator is perceived, the HOF program
could be influenced.
Moreover, most of the HOF programs that have been performed in companies
are mainly focused on the human factors that can influence human performance:
inadequate procedures, inadequate communication, inability to implement lessons
learned, perceived lack of management and commitment to safety. It is still a chal-
lenge to really implement programs addressing organizational factors with inputs
from sociology. When we analyse some recent big changes in organization (at cor-
porate or site level), it is clear that companies still have to improve their ability
to analyse organizational factors and customize their change program based on the
results of such analyses.
Training is one of the ways of making progress. Training must cover all the
employees of the organization, from the executive management to frontline workers.
When most of the HOF training is integrated in the baseline competencies training
program, efficiency is better. It facilitates the incorporation of HOF methods and
behaviours in daily management and operational tasks. With this practice, managers
strive to consider HOF methods as a further step to managing the organization,
broader than safety. Frontline workers are more convinced that HOF influence their
safety decisions and actions, and thus more likely to deliver safe acts.
One challenge for companies is to gather information on the tools, methods and
studies that have been used with success, with the relevant agility in a moving envi-
ronment. They could be established as a reference for some questions or problems
that were an issue in the past and have resurfaced in another branch of the company,
or sometimes, unfortunately, in the same branch.
A collection of good practices can also be made between companies, whether
they are from the same sector or not.
30 C. Neveu et al.

4 As a Conclusion

According to the benchmark of the different risk industries and to the international
experts’ points of view,4 we can say that a HOF approach cannot be reduced to
the use of methods and tools. At the core of such an approach, a strong conviction
from the top managers of the organization is required, expressed by a clear ambition
(i.e. strategic vision and required means) and a strong commitment that is visible to
everybody in daily decisions and behaviours.

References

1. J. Reason, Managing the management risk: New approaches to organisational safety, in Reli-
ability and Safety in Hazardous Work Systems: Approaches to Analysis and Design, ed. by B.
Wilpert, T. Qvale (Lawrence, Hove, 1993), pp. 7–21
2. B. Wilpert, B. Fahlbruch, Safety related interventions in interorganisational fields, in Safety
Management and the Challenge of Organisational Change, ed. by A. Hale, M. Baram (Elsevier,
Oxford, 1998)

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter’s Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter’s Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.

4 The experts that participate in the FonCSI residential seminar held in January 2018 (Editor’s note).
The Key Drivers to Setting up a Valuable
and Sustainable HOF Approach
in a High-Risk Company such as Airbus

Florence Reuzeau

Abstract Airbus has been investing in developing human and organizational factors
(HOF) approaches for the last three decades. With hindsight, we can identify and
capitalize on the key drivers for setting up a valuable and sustainable HOF approach
in a high-risk company such as Airbus. These drivers can be the role of regulators, the
standardization and visibility of HOF approaches within the company, HOF gover-
nance and competence management. However, there is no room for complacency in
a competitive market with regards to sustaining HOF approaches at the appropriate
level. Therefore, the message should be to define and measure what can be described
as HOF maturity indicators to be integrated into the company dashboard.

Keywords Human factors · Organizational factors · Standards · Competences ·

Governance · Maturity

1 Introduction

The development of human and organizational factors (HOF) approaches in a large

group depends on very different factors such as the expected benefits, obligations
(certification), induced cost and organizational structure of the company. In Airbus,
there are two endemic issues: human factors and organizational factors.
The first issue relates to the human factors (HF) at workstation for the work-
ers (or blue-collars) in the plants as well as for the human operators of an aircraft:
reducing the effect of working conditions on the Health and Safety of human oper-
ators, enhancing the safety of air transportation, supporting the introduction of new
technologies, machines, tools, or new operational procedures. Productivity and cost
reduction are part of the equation, as are cost of design, industrialization and end-
user training. Whatever the domain of application, the key challenge today and for
the future is to understand and anticipate how human operators can behave and will

F. Reuzeau (B)
Airbus, Toulouse, France
e-mail: florence.reuzeau@airbus.com

© The Author(s) 2020 31

B. Journé et al. (eds.), Human and Organisational Factors,
SpringerBriefs in Safety Management,
https://doi.org/10.1007/978-3-030-25639-5_5
32 F. Reuzeau

behave in their daily operations. This is particularly challenging for the aircraft prod-
uct as they are designed to be used for around 40 years, meaning there will be two
or three generations of multi-cultural human operators. Disciplines such as psychol-
ogy, ergonomics, sociology, linguistics and neuroscience are fully integrated into the
company to cope with these aspects.
The second issue relates to organizational factors (OF). Airbus is an international
company whose research, development, production and customer services activities
are distributed in Europe and around the world. How can international organizations,
processes, methods and tools be conceived to be usable by any employee in order to
design, produce and deliver the order backlog, taking safety, security and profitability
into account? In addition, company performance is subject to the performance of the
whole extended enterprise, the suppliers and the subcontractors. Moreover, there
is some internal testing of new organizational ways of working such as liberated
enterprise, agile methodology, remote work. It is very difficult in such an organization
to differentiate the implications of individual versus collective factors on the work.
Management sciences, psychologists and sociologists from Human Resources
are supporting these actions in a transnational mode. It is quite a new phenomenon
compared to the introduction of human sciences in the human factors field.

2 History, Looking Back

Airbus historically invested in HOF approaches in industrial production mainly for

Health & Safety considerations. In 1984, the first “ergonomics department” was set
up in the manufacturing organization to develop “work analysis” as a key method-
ology for supporting the introduction of new and novel machines, tools, product
lines and new buildings. This included working organization, job instructions, train-
ing, etc. In 1993, the decision was made to allocate one ergonomist position per
plant and assembly line to support management decision-making. The great diver-
sity of human factors issues (physical ergonomics, cognitive ergonomics, health,
mixed workers generation, competences, robots/cobots, and new technologies like
augmented reality, etc.) and the chasing of human-induced non-quality make this
job quite challenging. Today, the company is engaged in the digital transformation
through the factory of the future. Airbus mandated an ergonomist coordinator to
gather and share best practices among the facilities distributed in Europe.
In 1988, the Airbus Training Center was also provided with a small team of people
with human factors competences in charge of developing and deploying teaching
techniques and working with instructors to define training policies (in line with the
Crew Resource Management courses).
Early 1990s, it was decided to set up a new HF organization for supporting the
commercial aircraft design process, with the objectives of enhancing safety and cus-
tomer efficiency. Although this evolution was first initiated by an Airbus employee,
it must be situated in the context of an epoch for aviation and human science. In
1996, the US authorities launched a worldwide review of HF integration in the
The Key Drivers to Setting up a Valuable and Sustainable HOF … 33

aeronautical domain, where the FAA (Federal Aviation Administration) called on

very well-known and legitimate HF scientists. Following statistical analyses of com-
mercial accidents and incidents, human errors were identified, and continue to be
identified, as a first-rate causal factor [4]. At the same time, it had become obvious
that the human sciences could not only offer an explanatory assessment of aviation
accidents but could also provide a positive contribution in aircraft design and oper-
ations. This resulted in the definition of a first lever for an efficient HOF approach:
the role of regulators.

3 The Role of Regulators: Pushing Safety Requirements

and HOF Induction

The first lever driving considerations of human factors in product certification was the
“strong recommendation” from the FAA to use “at the edge human science knowl-
edge”. This shared awareness between industries, academics and regulators gradually
led to an evolution of the certification texts. This initiative was part of a time of for-
malization and dissemination of human science knowledge in a way usable by the
industry. Of course, a series of ergonomics criteria, automation and computerization
considerations [3] already existed but spread across various documents [2]. The first
ISO 13407 (Human centered design process for interactive systems) was issued in
1999 before being extended to ISO 9241 [6] which incorporated a huge number of
relevant requirements and guidance to support a “User centered design” approach.
Standards and regulations are today available to regulate new aircraft projects (ARP
5056 [1], CS 25-1302, RTCA SC-233). They define safety standards and set out
strong recommendations for demonstrating compliance to regulations. Beyond the
HF criteria, compliance also recommends setting up a HF process throughout the
design and certification phases.
The regulators elaborate requirements on OF matters too. We cannot avoid men-
tioning a very important process that contributes to ensuring aviation safety: the
SMS (Safety Management System). It is defined as: “a systematic, explicit and com-
prehensive process for managing safety risks”. As a global risk management sys-
tem, the Safety Management System provides for goal setting, planning, measuring
performance and proposing action for improvement.

4 Standard HF Processes in Aircraft Design Engineering

Airbus fully defined and integrated its own “HF design & certification process” [8].
It is based on the adaptation of 9241-11 to Airbus context. Today it is considered
to be a mature process for addressing the current human challenges. The Airbus
Human Factors Design Process (HFDP) is a set of activities at system and aircraft
34 F. Reuzeau

level that defines (1) the human operators’ tasks and needs; (2) the HF issues and
benefits related to human(s)-machine interaction; (3) the expected performance of
the human-machine; (4) the validation plan to demonstrate the expected performance
of the human-machine. It can be done through analysis or simulation with end-users
in the loop using a scenario-based approach; and finally demonstrating compliance
with HF certification. The HF process application is led by HF specialists who work
in an integrated team (end users, designers, HF) for the duration of a technical project.
Regulations do not only govern design, but also flight operations, procedures,
pilot training, maintenance operations, simulator qualification in the form of the
“Operational Suitability Data” (OSD) mandating that aircraft manufacturers, who
have to submit data to EASA, consider important for safe operations.
As with the other Airbus processes, standardization is key and can be considered
as a second lever towards long-term change in the industry.
The Airbus HFDP is part of the other engineering processes along with quality,
safety, and validation processes. The Airbus design office numbers several thousands
of engineers worldwide and even more when encompassing the extended enterprise
perimeter. Standardized HF process, requirements and guidelines (such as a Cockpit
Philosophy) and shared HF evaluation methods are contributing factors for develop-
ing a consistent cockpit and cabin product whatever the diversity of design teams or
the diversity of profiles, culture, experiences and job assignment in the supply chain.
Why is it so important to define a standard process? Because a repetitive process,
independent from any specific context, is more likely to change the internal way
of working. It allows a comprehensive application of the process without having to
negotiate the conditions on a case by case basis.
Other industries developed or are currently developing their own HF process.
In 2010, a group of industries coming from ground, air and naval transportation,
powerplant and government bodies shared their best practices through a series of
workshops under the AFIS umbrella [5]. AFIS stands for the French Association of
System Engineering. Eurocontrol has also created a common HF process to steer Air
Navigation Service Providers to develop and deploy the new Air Traffic Management
solutions, for increasing traffic capacity in a consistent manner (Human Performance
Assessment Process) as described in Pelchen-Medwed and Biede-Straussberger [7].

5 HOF: Governance and Organization

The third lever is HF governance. Engineering and customer services top manage-
ment mandated in 2015 a HF board to ensure proper decision-making and follow
up on HF activities. The HF board is a decision-making authority and is composed
of top managers and high-level human factors experts. The top managers cover the
functions for which human factors can highly impact aircraft safety, the health and
safety of workers or the global efficiency of Airbus product for customers. Safety
management needs a global consideration of human factors. It includes the definition
of a clear, unified HOF strategy, policies and priorities for all Airbus products and
The Key Drivers to Setting up a Valuable and Sustainable HOF … 35

processes (aircraft, documentation, training, maintenance, etc.). The board allows

HOF to be considered as a cross-functional discipline across organizations. Aircraft
safety, flight testing, systems design, industrial quality, aircraft programs, architec-
ture and customer services are discussing how to establish a consistent philosophy on
implementing and disseminating HOF throughout the aircraft cycle. For example, if
an in-flight event that occurred in service is classified as human factors, it is analysed
from the design and the operational point of view with a consistent model of human
behavior. The HF board is key for assessing, explaining, analysing, and predicting
the impact of HOF in political, economic and safety-related scenarios and decisions.
This decision board helps to promote the visibility and the legitimacy of human
factors in the company. It reinforces the recognition and the authority of HF through
the involvement of top managers. It is also a way to share and coordinate cross-
organizations.
In term of implementing HF in the business, Airbus decided to organize HF in a
decentralized manner. It means that several HF specialist teams are located near to
their respective centres of competence. For instance, one HF organization is located
in the cockpit design centre of competence, another one is in the cabin domain. High-
level experts oversee technical coordination. A network of human factors specialists
has been set up to allow any HF specialist to know and exchange with any HF
colleague within Airbus overall.
On the production side, a similar network was organized as a real asset to cope
with the specific difficulties of this sector. Unlike in the engineering environment,
the ergonomics specialists are spread across the European plants and Final Assembly
Lines (FAL) and can feel as if they are working in isolation from other HF specialists.
Promoting networking inside a HF community is a favorable condition for HOF
performance.
Poor ergonomics in manual handling operations are identified as the second
most common cause of long-term injuries in the Airbus production sector. Musculo-
Skeletal-Disorder (MSD) is the most common cause of absence with a significantly
high number of days lost per year, as has been the case for many years. This aware-
ness led to the implementation of a network of dedicated ergonomists working in all
production plants across Europe.
The network is also covering the Final Assembly Lines (FAL). A central coor-
dinator is in charge of managing the network, sharing best practices amongst the
facilities and defining the strategy for ergonomics in production. One of the results is
a common document of aligned rules, which are derived from international standards,
national obligations and specific requirements in terms of ergonomics with respect
to Health & Safety. They are applicable to all plants, FAL, and also provided when
a new line design is subcontracted to suppliers. Based on the key indicator methods
(holding, lifting, carrying, pulling, pushing) ergonomic conditions and MSD relevant
activities are screened and anticipated.
Countermeasures are taken to correct the past and also prevent for the future.
Even when manual handling operations of loads and associated postures do not
completely cover the full set of ergonomics, it is essential to interact at an early stage,
referring to the known number of injuries.
36 F. Reuzeau

Beside of these ergonomics considerations, workstation design on the shop floor

is also influenced by different environmental factors i.e. organization (time), logistics
(tasks and flows) and interaction (human-machine).
This becomes important whenever ergonomic analyses are made, especially when
investigating alternative scenarios, working with collaborative robots, smart tools etc.
In order to get full integrity, we are aiming to achieve valuable ergonomic
conditions across the chain of Engineering, Manufacturing and Maintenance.
This will reduce the number of lost time injuries and increase the safety and
quality of work and ultimately the health of employees. Furthermore, it is key for
future production design, helping the company to be competitive and efficient.
Quite recently and after a long period of “independence”, the different HF orga-
nizations (engineering, customer services and production) moved closer in order to
exchange on topics such as “human and robots”, smart tools, cognitive assistants
and the use of big data to better understand actual human operator behavior. The
improved connection between Engineering and Manufacturing is not specific to HF,
it is part of the ‘factory of the future’ project to better consider the manufacturability
requirements in the design so as to reduce the lead time and cost of operations. HF
should be involved at the appropriate level for the benefits of the workers and work
organization.
One of our most important projects is now to collectively review the current
HOF to face the future challenges as new concepts of operations (Reduced team
operations, factory of the future, remote control room…) and new kind of tech-
nologies associated with increased automation, augmented intelligence systems,
robots/cobots…Consequently, new HF competences, new ways of working and new
standards need to be invented.

6 HOF Competence Management

The fourth lever is competence management. In-service event analysis shows that
Runway Excursion, Loss of Control, and Control Flight Into Terrain are persistent
events. Human error is often cited as a primary cause or contributing factor in most
accidents. It means that we need to reinforce HF education in the aviation community:
HF related to approach and landing management, energy management, attention allo-
cation, crew fatigue, manual flying following automation degradation, or procedure
management are just examples. As such, the competencies implemented to apply the
HF approach are a combination of human sciences (cognitive psychology, linguistics,
physiology, human-machine interaction, sociology), operational knowledge (pilots,
cabin crew, etc.) and engineering skills. Airbus decided to recruit these specialists.
HF specialists are always a small group of people among thousands of engineers.
They can be considered as “cost/time constraint” and of course as troublemakers
when challenging the “expected human behaviors’ assumptions” of the engineering
staff. As a minority, human factors specialists should always demonstrate their added
value in front of a “monocultural engineering world”. Educating a large number of
The Key Drivers to Setting up a Valuable and Sustainable HOF … 37

engineers and managers in HF should help to reinforce the efficiency of a multidisci-

plinary team, but it is costly. The aviation industry is helped by a series of initiatives
that disseminate human science knowledge. For example, Yeh et al. [10] issued a
report on human factors considerations in the design and evaluation of flight deck
displays and controls. For its part, Airbus is currently developing a set of rich media
and a knowledge pack using the company intranet and low-cost dissemination tools.
Nevertheless, we are investing in HF experts and their career path. These experts
are an asset for the company. They have a strong academic background in the most
relevant human science disciplines and have acquired much on the job experience.
They work together and are responsible for the development of HF competences in
their centre of competences. They are known by the management and responsible
for elaborating the vision in their domain of expertise.
But we can ask ourselves how to develop a stronger footprint, looking at how
the “User eXperience (UX) design” community has rapidly won new markets. UX
design is a process of designing (digital or physical) products that are useful, easy
to use and, above all, a pleasure to interact with. It is about making sure the end
users find a hedonic value in the usage of the product. Even if UX design studies
have a direct impact on sale and revenue as they are directly impacting the “mass
buyer” whereas HOF in industry is generally impacting the employee performance,
and rather a source of cost and not a direct source of revenue. But let us be creative
to offer the best product to the end users, integrating the conventional HF qualitative
values and hedonic values in a same HF label.

7 Conclusion, HOF Maturity

Regardless of our efforts, these four levers cannot be enough to guarantee the success
of the HOF approach in the future.
New technological developments and economic changes offer a large number of
opportunities but also important challenges for organizations. Among these evolu-
tions, autonomous transportation, connectivity, IOT (Internet Of Things), robotics
and artificial intelligence will have a huge impact on human life as well as on human
operators at work.
Staying aligned with the strategic objectives and preparing the future is paramount
for companies. The previous levers for implementing HF standard processes, HF gov-
ernance, and competence management are the critical ingredients of a HOF maturity
framework to guarantee that:
• the projects deliver as expected,
• the projects selected are the ones that support the company strategy and bring the
best benefits: selection of the most critical projects with a high added value. For
example, the selection should include the “burning” projects, the ones that solve
important issues in daily operations as well as the project that drive the research
strategy,
38 F. Reuzeau

• the teams have the appropriate knowledge, process, methods and tools,
• the HOF organization has the necessary capacity to continuously anticipate the
evolutions (adaptability, change mindset),
• the HOF organization is sustainable and robust. It is independent enough from the
human factors specialists in charge of HOF.
A suggestion would be to measure HOF maturity on a regular basis to identify and
understand what is useful or not so useful, or to identify how to achieve a higher
level of maturity.
This is key to setting up a valuable and sustainable HF approach.
The level of maturity should define the “predictability, effectiveness, and control
of the HOF”. HF governance allows the improvement process, that is the highest
level of maturity. We could summarize the HOF maturity level in the Fig. 1.
The model provides a theoretical continuum along which process maturity can
be developed incrementally from one level to the next. Skipping levels is not
allowed/feasible.
As a conclusion, we may recommend setting up efficient HOF approaches. First
of all, to integrate the HF processes into the current/existing business organizational
model of the company processes, with the same level and the same visibility compared
to other processes. Second, to set up HF governance at the higher level of management
to share the risks of not having an appropriate HOF approach and define the suitable
HF strategy. And third to elaborate relevant indicators to measure the maturity level
of HOF and to monitor it on a regular basis to ensure optimal consideration of
HOF. These fundamentals should allow us to shape the significant changes we see

Fig. 1 Level of HOF maturity [adapted from integration of the test maturity model (TMMi [9])]
The Key Drivers to Setting up a Valuable and Sustainable HOF … 39

as robotics increase (between 1993 and 2007, robot density increased by more than
150%) or digitalization expands without overly penalizing the working conditions
of human operators.
This is crucial for a business that must adapt to new market challenges and
customer expectations.

References

1. ARP5056, Flight crew interface considerations in the flight deck design process for part 25
aircraft. SAE 2006-07-05 (n.d.), https://www.sae.org/standards/content/arp5056/
2. L. Bannon, Issues in design. Some notes, in User-Centered System Design, ed. by D.A. Normal,
S.W. Draper (Lawrence Erlbaum Associates, 1986), pp. 25–29
3. C.W. Billings, in Aviation Automation: The Search for a Human-Centered Approach (Lawrence
Erlbaum Associates, 1997)
4. FAA human factors team, The interfaces between flight crews and modern flight deck systems.
FAA report (1996)
5. E. Gardinetti, D. Soler, F. Reuzeau, C. Maïs, X. Chalandon, Ingénierie des facteurs humains,
in ERGO IA2014, Biarritz, October 2014
6. ISO 9241-210, Ergonomics of human-system interaction—Part 210: human-centred design for
interactive systems (2010)
7. R. Pelchen-Medwed, S. Biede-Straussberger, Effectiveness of the application of the HP
assessment process in SESAR1, in USA/Europe ATM Seminar/Seattle, 26–30 June 2017
8. F. Reuzeau, Human factors design process: benefits and success factors, in 3rd Human
Dependability Workshop (HUDEP 2013), ESA. Munich, 13 & 14 November 2013
9. TMMi, Test maturity model integration, (the TMMi Model). TMMi Foundation (n.d.), https://
www.tmmi.org/tmmi-model/
10. M. Yeh, J. Young, C. Donovan, S. Gabree, Human factors considerations in the design and
evaluation of flight deck displays and controls. Version 1.0 final report—November 2013
DOT/FAA/TC-13/44 (2013)

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter’s Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter’s Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Developing Human and Organizational
Factors in a Company
Some Lessons from Ergonomics?

François Daniellou

Abstract The issue of the development of human and organizational factors of

industrial safety in a company can be nourished by the experience gained from
ergonomics. The author draws lessons from some French examples.

Keywords Ergonomics · Organizational design · Human factors

1 Introduction

“If we want to develop human and organizational factors in the company, how
should we organize it?” This is basically the question that industrial groups have
asked FonCSI to examine in this strategic analysis. The issue relates, of course,
to the consideration of human and organizational factors of industrial safety. My
past career as an ergonomics teacher leads me to suggest that it could usefully be
nourished by an understanding of the successes and failures of the development of
ergonomics in French companies.
The relationship between the terms human and organizational factors and
ergonomics is unclear. For the International Ergonomics Association, human factors
and ergonomics are simply synonyms, and are covered by the same definition:
Ergonomics (or human factors) is the scientific discipline concerned with the understanding
of interactions among humans and other elements of a system, and the profession that applies
theory, principles, data and methods to design in order to optimize human well-being and
overall system performance.

In the field of industrial safety, the terms human factors (HF) or human and
organizational factors (HOF) have a wider scope: they refer to the multidisciplinary
study of the conditions that foster an efficient and safe human activity, and they
encompass the contribution of all individual and collective human sciences.

F. Daniellou (B)
FonCSI, Toulouse, France
e-mail: francois.daniellou@foncsi.icsi-eu.org

© The Author(s) 2020 41

B. Journé et al. (eds.), Human and Organisational Factors,
SpringerBriefs in Safety Management,
https://doi.org/10.1007/978-3-030-25639-5_6
42 F. Daniellou

The trend is towards a reconciliation of these two approaches: organizational

dimensions are becoming more and more a concern for ergonomists, due to the
development of interventions in design phases on the one hand, and to the prevention
of musculoskeletal disorders and psychosocial risks on the other.

2 Some Industrial Examples

In France, the first industrial ergonomics lab was created in 1955 at Renault by
Wisner [2]. While its founder wanted to address the ergonomics of plants as much
as that of cars, the senior management did not permit it. Their main concern was to
design cars that allowed the largest number of people to drive (and therefore buy)
them. Only much later did ergonomists and “sociotechnical engineers” participate
in the design of assembly lines: the concern was then to maintain in employment a
large population of workers aged over 40.
In the field of chemistry, Rhône-Poulenc played a pioneering role in the 1980s
with the design of control rooms. After difficulties encountered at the start of several
industrial projects, Jacques Laplace (a Human Resource manager), Denis Regnaud
(a socio-technician) and Michel Guy (an ergonomist) formalized a systematic par-
ticipatory HOF approach to design projects, including the early assignment of future
operational teams, and their association with the project in the frame of an “Opera-
tional Project Team” [1]. Regrettably, after several years of success, investments in
France dried up and the approach was discontinued.
In the aircraft industry, at Aerospatiale, a double development took place: on the
one hand, a strong contribution of ergonomists to the industrial design of assembly
lines emerged in the late 1980s; on the other hand, there was a notable development
in the human factors of cockpit design after the Mont Saint-Odile accident (due to
regulatory pressures and thanks to several internal and external sponsors). Those
two dynamics have been perpetuated and are currently converging (see Florence
Reuzeau’s chapter in this book).
Assistance Publique Hôpitaux de Paris,1 in the late 1980s, made the presence
of ergonomists in the design of new hospital units mandatory and created for this
purpose a central ergonomics department, which has now disappeared.
At EDF2 the “ergonomics/HF” concern developed in several departments: in the
occupational medicine department around occupational health, in the Nuclear Pro-
duction Directorate for the issue of nuclear safety, particularly in the Engineering
department for the design and modification of control rooms and procedures—draw-
ing the lessons from Three Mile Island accident—, in the R&D department for nuclear
safety, as well as for the usability of software and home automation.
This list of examples is, of course, non-exhaustive but may help us to try and draw
some generalisable lessons.

1 Which manages all public hospitals in Paris.

2 The historical French electricity operator.
Developing Human and Organizational Factors in a Company 43

3 Some Success Factors

The emergence of “ergonomics/HF” departments always results from a combination

of:
• a major threat for the company (industrial accident, repeated failure of investment
projects, number of occupational diseases, low product attractivity…);
• the sustained involvement of internal individuals, educated in ergonomics, and of
industrial decision makers who have been convinced by significant examples;
• in the case of energy and aeronautics, the role of regulatory bodies who pay
attention to this focus and impose minimum standards.
The following factors of success may be identified.

3.1 A Close Connection between Practitioners and Academics

The development of French-speaking ergonomics has been marked by a strong con-

nection between academic institutions and practitioners, including within SELF, the
Société d’ergonomie de langue française. On the one hand, academics made impor-
tant efforts to offer continuous education programmes for practitioners, allowing
them to update their knowledge according to research developments. On the other
hand, and most importantly, some labs have developed ‘research on practice’, start-
ing from researchers’ field interventions as well as from sustained interactions with
internal or consultant practitioners. These exchanges allowed a common analysis of
successes and difficulties, and the discussion of ‘models’ of interventions on various
topics (in investment design projects, for the prevention of musculoskeletal disorders
or psychosocial risks, etc.). Most ergonomists who were ‘pioneers’ in their company
belonged to such academic networks.

3.2 Leading by Example

The story of the development of ergonomics in an organization often starts like

this. Well before ergonomics/HF have an acknowledged status in the company, one
or several individuals of relatively low rank, and/or an external consultant play an
outstanding role in using HF methods to overcome a problem which the organization
had, until then, been unable to resolve. Some such examples attract the attention of
high-level decision makers, who firstly issue multiple requests, then advocate for an
institutionalization of the approach.
44 F. Daniellou

3.3 Organization around Key Processes

The most sustainable examples are those where the ergonomics/HF approach is
structured around the company’s key processes.
Let us take the example of the PSA group, which employ several dozen
ergonomists. Some of them contribute to vehicle design (increasingly so, due to
the digitalization of driving). Others are assigned to the design of assembly lines
and plant units (giving feedback on the car design to ensure its manufacturability),
others to production plants. The last two groups have the same management team
and ergonomists switch from one to the other.
The key processes—“product design”, “design of production means”, “opera-
tion”—are the most common, but probably not the only ones. Ergonomics/HF are
usually mobilized to ensure (together or separately) safe and easy use of the product,
production quality and occupational health and safety. In some cases, the humans who
are the targets of the action are customers or users, in some cases they are employees,
sometimes both (the design of a car that be saleable and manufacturable).
Of course, those key processes will evolve, as will the respective weights of the
stakeholders who embody them. Detecting these evolutions and adapting the response
is a key element of a sustained contribution of ergonomics.

3.4 Combining Ready-Made and Haute Couture

The sponsors of the ergonomics/HF approach rapidly became aware that it was not
possible to have an ergonomist standing behind each design engineer to ensure,
as a minimum, compliance with anthropometric and perceptive standards. It was
necessary to guarantee and assess the integration of basic ergonomic prescriptions
from the very first drawings, without waiting for the project reviews which generate
late, expensive and conflict-provoking modifications.
One of the first tools designed with this objective was the famous ‘Renault grid’,
which allowed for an early scoring of work stations, and led to prohibiting those that
entailed significant risks. Like other tools that have successfully followed this one,
it presented the following features:
• good usability, requiring only a few hours of training;
• a transversal nature, which made it a boundary object between designers,
production managers and HF specialists;
• a mandatory character, with the commitment not to produce work stations with
extreme scores;
• periodic revision—albeit not too often—to integrate new risks and new knowledge.
Developing Human and Organizational Factors in a Company 45

While being heavily criticized by the most purist external ergonomists for its ‘sim-
plistic’ nature, this tool played a considerable role in the integration of an ergonomic
‘minimum’ throughout the whole group. It also freed up ergonomists for tailor-
made interventions where their skills were mobilized at a higher level. Haute couture
becomes a de facto necessity for the design of an efficient and safe work organization.
Beyond the circulation of these historical standards, some companies today pro-
vide managers and project leaders with HF procedures and methods, e.g. for analysing
adverse events, anticipating the socio-organizational consequences of a change, etc.
These approaches are the object of training programmes and an accompaniment by
HF specialists.

3.5 Associating Health and Performance

If interest in occupational health and safety is real in some companies, for human
and/or financial reasons, it is seldom enough of a concern to ensure the allocation of
the resources needed for the structuration of ergonomics/HF in the organization.
The demonstration of the contribution of human work to the organization’s global
performance is always necessary, if this approach is to be implemented. It can be
based on different statements: quality improvement (decrease of defects and scrap),
increased flexibility of production, improvement in the operation rate of machin-
ery, reduction in absenteeism and employee turnover, winning demanding clients,
prevention of major industrial risks.

3.6 Micro and Organization Levels

One of the main features of the ergonomics/HF approach is to constantly connect

the “microscopic” understanding of activity in the workplace with organizational or
strategic dimensions. Many ergonomists have in the last 20 years followed a route
that led to influence higher order determinants, those connected to work and company
organizations. This attempt proves more successful when their intervention occurs at
the early stages of technical or organizational design rather than in curative actions.

3.7 The Central/Decentralized Mix

In many cases, the structuration of the ergonomics/HF approach combines:

• specialists who are seconded close to the operational trades and sites, whose actors
and processes they know in depth;
46 F. Daniellou

• a light-handed central team, which defines generalisable processes and fosters the
sharing and capitalization of experiences. They also act as a two-way relay with
the top management.
This structure is similar to the one that can be found in HSE departments in many
cases.

3.8 Some Specialists and a Network

Whatever their number and competence, ergonomists alone cannot detect and influ-
ence all processes where a HF approach would be required. They must rely on a dual
network:
• an internal network of correspondents, interested managers and, in certain cases,
personnel representatives, who have been trained and act as informants and relays
with the trades;
• an external network of trusted consultants, to whom some of the interventions may
be subcontracted, and with whom a joint elaboration of generalizable lessons is
possible.

3.9 A Solid and Discreet Theory

In countries inspired by ‘activity ergonomics’, training in ergonomics emphasises the

gap between prescribed work and real work, the constant adaptation of the worker’s
operating strategies to cope with the variability of the work situation and his/her
own variability, the importance of the vitality of the work group, the physiological,
cognitive and psychological strain related to various tasks, etc. The curricula also
provide classic intervention methods that may be adapted to each specific situation.
The theoretical background of the ergonomist’s intervention is a solid one and is
regularly discussed and updated in professional meetings.
Nonetheless, the ergonomists’ professional success relies mostly on their capacity
to speak their partners’ language rather than that of their professors and on their
ability to introduce the HF approach as naturally as possible in existing structures
and processes.
This dialogue requires the sharing of some HOF knowledge and practice with
counterparts, through training programmes which allow them to discover how this
approach may enlighten some of the issues they have to deal with and enhance their
own professional practice.
Developing Human and Organizational Factors in a Company 47

4 Avenues for Progress

Although, in some companies, the HOF approach seems solidly anchored, major
difficulties relate to:
(1) the sustainability of actions which have been launched by confident managers,
and may be under threat when they leave;
(2) the interface between the different departments in charge of the domain.

(1) To address this vulnerability, it is necessary to anchor practices that become

inescapable in the organization as a consequence of their broad dissemination
and their acknowledged contribution.
(2) Taking the human contribution into account in design and organizational deci-
sions is a multifaceted issue: it includes product usability, attractivity and
safety; operability of industrial facilities, ergonomics of work stations; orga-
nization of R&D programmes; operational excellence, lean production; indus-
trial safety, occupational health and safety; incentive and sanction policies,
company’s attractiveness, skills and age management, induction programmes
and career management; social dialogue, participation, profit-sharing; industrial
subcontracting policy…

In a major group, these issues are supported by different departments, that may
carry distinct models of the human and of the organization. These organizational
silos may be a source of contradictions. A well-known hospital example is the con-
tradiction between wearing gloves, which is prescribed by the occupational health
department to protect caregivers, and washing hands, which is recommended by the
patient safety department to prevent nosocomial infections.
Individual contact between specialists from these different worlds usually exists,
of course. What is at stake today is a shared (and therefore debated) vision of the
conditions of human work that is efficient, safe, favourable to personal development,
and a deep understanding of its contribution to the company’s global performance.
If the horizon of such a generalization may seem distant, two dynamics may
contribute to bringing it closer:
• Serious HOF educational programmes for managers and personnel representatives
(at the university level as well as in the company) that help to overcome such clichés
as “if all procedures were followed, there would be no problem” or “what you can’t
measure doesn’t exist”, and make it possible to establish minimal HOF steps in
the processes;
• Multiple interactions between Human Resources, engineering departments, pro-
duction, HOF and health specialists, in a context of technical and organizational
design projects implemented with the strong participation of operation managers,
employees and personnel representatives.
48 F. Daniellou

What is eventually at stake is less the structuring of a HOF department than

‘HOFizing the organization’,3 or in other words, impregnating it with concern for
the conditions of efficient and safe human work.

References

1. J. Laplace, D. Regnaud, Démarche participative et investissement technique: la méthodologie

de Rhône-Poulenc, in Cahiers techniques UIMM, vol. 52 (UIMM, Paris, 1986)
2. A. Wisner, Quand voyagent les usines (Syros, Paris, 1985)

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter’s Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter’s Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.

3 According to Hervé Laroche.

Organisational Factors, the Last
Frontier?

Ivan Boissières

Abstract Significant advances have been made in the field of human and organisa-
tional factors (HOF) integration in industrial groups these last decades. Nowadays,
HOF are generally quite structured in companies, in the form of a coalition between a
few key departments and their allies. Nevertheless, various features limit their scope,
notably in their impact on the organisation. First, we must acknowledge that the ‘o’
in Human and organisational Factors is a small ‘o’. What lies behind this statement is
that the human factors approach dominates, and the purely organisational approach is
given far less attention. Then the various approaches usually remain limited to safety
issues. HOF issues are rarely considered in strategic trade-offs, or in restructuring
or management discussions. Finally, since the success of HOF implementation is
mostly built on the political will and relationships of a few key individuals with top
managers, they usually do not persist when these people leave. Beyond these obser-
vations, this chapter, based on a solid experience of HOF approaches that have been
implemented since the 2000s in different industrial sectors, explores the underlying
reasons for these limitations and proposes some ways forward for a better integration
and sustainability of HOF in high-risk companies.

Keywords Organisational factors · HOF coalition · HOF supply

1 Introduction: Human and Organisational Factors

with a Small “O” (HoF)

Many high-risk companies often present the incorporation of human and organisa-
tional factors (HOF) as the last step in their safety strategy, after having first taken
essentially technical then procedural measures.
There is no doubt that this approach has allowed progress to be made in the
dissemination of the major concepts illustrating the human contribution to safety.
For example, there is a growing acceptance of the difference between work as done

I. Boissières (B)
Icsi, Toulouse, France
e-mail: Ivan.Boissieres@icsi-eu.org
© The Author(s) 2020 49
B. Journé et al. (eds.), Human and Organisational Factors,
SpringerBriefs in Safety Management,
https://doi.org/10.1007/978-3-030-25639-5_7
50 I. Boissières

and work as imagined. Many companies are considering the importance of managed
safety as a complement to rule-based safety and this tends to be reflected in their
structuring of human and organisational factors.
However, some practices are struggling to truly evolve:
• Major reorganisations are still essentially technocratic and their impact on work
groups and safety is rarely anticipated.
• Beyond awareness campaigns with little or no follow-up, it is very difficult to
invest in HOF skills for operational managers.
• Leadership from company executives is affected by a high turn-over rate, thus
undermining continuity in terms of HOF approaches.
• Safety is still only marginally integrated into the organisation’s key processes
(design, human resources, finances, etc.). Therefore, its place in the strate-
gic decision-making process can be seriously weakened when the company is
experiencing financial turbulence.
On closer examination, these limitations seem to be concentrated around organ-
isational factors in the broad sense. Could it be that the term HOF actually hides
different realities? It must be acknowledged that the ‘o’ in human and organisational
factors often is a small ‘o’. On the one hand there is the progress made by the human
factors approach, which focuses closely on workers and the reality in the field. On the
other hand, it seems to be more difficult to change the organisation and managerial
practices.
We propose to examine this hypothesis in more depth, based on experience of
HOF approaches implemented since the 2000s in high-risk companies.1 We will
more specifically explore potential causes of this blockage not on the demand side
(resistance of organisations to change their practices), but rather on the HOF supply
side. Are the experts’ profiles relevant? Are there difficulties in appropriating fields
mostly peopled by general consultants and gurus and considered to be scientifically
weak? Is the HOF “coalition” powerful enough to allow an actual consideration of
HOF in companies?

2 Is the Role of Organisational Factors in the HOF Domain

Actually a Problem of Supply?

One of the main reasons why it is so difficult to fully take organisational issues into
account might be the profile of HOF suppliers, who are nearly all psychologists and
ergonomists, to the detriment of sociologists and management scientists. We truly
owe a lot to this community for raising the profile of human factors in companies.

1 This chapter is above all based on a personal experience of consideration of HOF in companies: first

as a Ph.D. fellow, then as an operational manager in a foreign subsidiary, and as an internal or external
adviser to the executive management of large French groups, in various sectors: telecommunications,
energy, transports, construction… Therefore, it may not be exempt from some overgeneralizations
or caricatures.
Organisational Factors, the Last Frontier? 51

However, consideration of organisational factors seems to be limited by some of

their specificities such as the areas they choose to work in, their relationship to
management, or even the theoretical framework.
The domains where human factors are considered relevant have changed greatly.
The focus has moved from operator protection, to optimizing their work, safety and
performance. There seems to be a desire to slowly ‘climb’ from the micro (the work
situation) to more macro dimensions related to the organisation of work. This has
been most successful in the field of the design (of a workstation or a factory). But it
has very rarely been used to address large-scale managerial or organisational change.
An organisational intervention also means changing who HOF specialists talk to.
Historically, they have been invited in by departments that are doing quite similar
work, such as the medical service or internal ergonomists. They also have interacted
a lot with front-line managers, i.e. the production or design team at the factory or
project level. Working on the organisation and major strategic decisions involves a
shift from the production line to the management line, or even to the level of general
management [2]. This represents a jump that is often difficult for HOF specialists to
make because they do not want to lose their credibility with workers in the field or
to be manipulated due to lack of leeway.
Finally, organisational factors appear to be a domain that is reserved for another
category of stakeholders—auditors and management consultants. The business world
is, in some ways, implicitly divided in two. Human factors approaches apply to work-
ing conditions (workers, safety, design) while auditors or management consultants
work on organisational problems, management and strategic decisions. It is appar-
ently difficult to overcome this division because, on the one hand, the human factors
community is very critical of the lack of scientific knowledge of management con-
sultants and of some so-called gurus. On the other hand, not many of these experts
are interested in safety issues. There do not seem to be many bridges between the
two worlds, especially since organisational sociologists—whose work is closer to
the ideas of human and organisational factors—have almost disappeared from com-
panies. In the nineties, it was common to find sociologists working at the top level in
companies such as Air France, RATP, Danone, Michelin, etc. As an example, during
my PhD at France Telecom, I worked with a sociologist who advised the general
management to support the reorganisation of one of its departments [4]. Nowadays,
the demand from companies for sociological support is so low, it is hardly possible
to quote such an example [6, 8]. The lack of development of organisational aspects
in HOF approaches is harmful because it risks locking those approaches into an
overly-limited view of the problem. Above all, rather like a ‘glass ceiling’, it might
block access to the level where solutions can most often be found: organisational,
management or strategic decisions.
52 I. Boissières

Fig. 1 The HOF ‘coalition’: the current situation

3 The Current HOF “Coalition”

How is the HOF approach currently structured in at-risk companies in France? Who
are the key actors, the members of the coalition that is driving progress? Where are
they located in the organisation?
First, we will address the external options the French HOF market has to offer.
As already stated in this chapter, the supply is mostly composed of experts with
experience in human factors and ergonomics, working in small consulting companies.
This community is well-structured; its members are part of an association, the SELF
(The Society of French-speaking Ergonomists) and they regularly meet to share their
experience. In fact, there are many more of these external consultants than internal
experts.
Secondly, what are the current trends within companies? Based on experience
with several large industrial groups, some conclusions can be drawn (Fig. 1).
Some at-risk companies have centralised their HOF expertise. It may be the
responsibility of a single person, usually a former consultant, or an HSE2 employee
who has specialized in human and organisational factors. At best, it is a department
combining these profiles. In any case, it is a very lightweight structure that aims
to promote HOF approaches or to capitalize on local experiments in order to dis-
seminate them. It can also be supported by an R&D department staffed by HOF
researchers.
In some leading companies, there might be HOF specialists posted in the field.
In some cases, they have organised themselves into a network. For example, at the
French national railway company (SNCF3 ) or in the nuclear sector, there are human
factors consultants. But the relationship between headquarters and this decentralised
network is not always easy. On-site experts work closely with their colleagues and

2 Health, Safety and Environment.

3 Société nationale des chemins de fer français.
Organisational Factors, the Last Frontier? 53

have more in common with local managers than with a centralised HOF unit. Some-
times, they do not even belong to the same sector. At SNCF, for instance, the human
factors network is part of the human resources department and mainly deals with the
quality of life at work and occupational safety. Meanwhile, in the same company,
the central HOF department is part of the industrial safety division!
In the vast majority of cases, HOF falls within the remit of HSE structures, or
those responsible for major risks. For example, at Air France, the HOF unit is part
of flight safety. At SNCF it is part of railway safety, and at EDF,4 a French electric
utility company, of nuclear safety.
Finally, this small internal network, which is often somewhat disconnected, takes
its orders from a few decision makers who are convinced that the HOF approach
can help them solve their operational problems. However, these managers are still
very much in the minority, which generally leads to ad hoc requests. The Institute
for an industrial safety culture (Icsi), created in 2003 following the AZF accident
in Toulouse (France), promotes a collective dynamic which allowed to launch large
safety culture reinforcement programmes based on better consideration of HOF.
However, although these approaches are often initiated by top managers, they appear
difficult to maintain in the long-term when these managers change positions or leave
the company.

4 Proposals for Ways Forward

To overcome some of the limitations described above and reinforce the HOF coalition
so that it can work on organisational issues, here are a few ideas based on our
experience working with industrial companies.

4.1 Managers/Senior Executive Staff: Reaching a Critical

Mass

The first suggestion regards the relationship between HOFs and top managers. Con-
necting these two “worlds” is not easy because many top managers just have a few
vague ideas about HOF or have developed their own way of doing things. Typically,
they see the organisation as a structure only, or a set of rules and procedures where
top-down management and little participation from the employees prevail. They do
not really consider the impact on teams or power struggles as they implement changes
in the organisation.
This is exactly why HOF experts need to talk to the top managers. At the very
least, this reconciliation would allow them to share the basis of a common vision and
overcome some stereotypes. This should help to avoid misunderstandings or failures.

4 Electricité de France.
54 I. Boissières

Thus, the challenge is to build a critical mass of top managers who are open to
the HOF approach, rather than have a few lonely evangelists within the organisation.
Moreover, it is of importance that HOFs do not remain enclosed within the safety
department, because there is a risk of disconnection from the organisation’s other
strategic challenges.

4.1.1 Training: HOF as a Dimension of Management

and not as a Standalone Topic

Training plays a key role in the integration of HOF in companies, and there are certain
conditions that might foster success. In France, at least two training programmes had
a significant impact on HOF in the industry.

Icsi
In 2005, Icsi and François Daniellou launched a 2-day training programme on
HOF. This has proved successful since over 300 professionals attended it, creat-
ing demand for an executive master in HOF in partnership with ESCP Europe
Business School. To date, more than 150 managers have studied for this mas-
ter’s degree (https://www.escpeurope.eu/programmes/executive-masters/executive-
mastere-specialise-manager-des-organisations-a-risques). Unfortunately, participants
mainly consisted of HSE specialists and very few were senior managers or Executive
Committee members.
CEDEP5
Another training programme delivered by CEDEP is specifically targeted at Executive
Committee members of Sanofi and L’Oréal. This programme is very successful and
HSE specialists are not the majority of participants. However, it does not meet HOF
standards. The training session starts with leadership, organisational culture and change
management, and safety is addressed only much later.

These examples illustrate how difficult it is to get operational managers to attend

HOF training. It also shows that a promising avenue is to integrate HOF into man-
agerial training programmes instead of asking managers to attend specific HOF
sessions. Moreover, one of the conclusions of the strategic analysis carried out by
FonCSI6 on professionalism is that safety should be better integrated into professional
development rather than being taught separately [3, 7].
The best way to reach top management is with specially designed, internal training
programmes.

5 The Executive Education department of the INSEAD business school (European Institute of
Business Administration).
6 Foundation for an industrial safety culture.
Organisational Factors, the Last Frontier? 55

“HSE for Senior Executives” and “HSE for Managers”, Total

From 2011, Total launched 2–4-day training programmes targeting senior top exec-
utives and managers, respectively. The whole top management stratus is required to
follow this course that is based on a 360-degree assessment of safety leadership and
solid face-to-face training in HOF, followed by regular coaching.
Vinci Construction
More recently, Vinci Construction developed a one-and-a-half-day internal training
programme called “Managing Through Safety”, with a significant focus on HOF. It is
part of “Cap for Management”, the general, 6-day training programme for Vinci man-
agers. It covers the fundamentals of management: finance, HR, business, innovation,
etc. Even though the top executives stay for just a day and a half, the part they attend
is dedicated to safety.

4.1.2 …so that Managers’ Vision and Practices Can Evolve

The integration of HOF to other managerial challenges implies that current HOF
specialists should be receptive to general management topics like power relations,
corporate culture, leadership, change management, etc. It also involves encouraging
more leadership or change management specialists to take an interest in safety. And,
finally, it means that the topic should be included in internal management training
courses, and externally by getting business schools to offer HOF training.
The real challenge is not to improve the marketing of HOF training programmes
for managers. Above all, the objective is to profoundly change the attitudes of man-
agers and management models that often represent an obstacle to giving proper
consideration to HOF in companies.

4.1.3 Open up HOF Networks to Operational Managers

We stated earlier that decentralized HOF networks are sometimes found in companies
with on-site internal consultants, or in business divisions. But they are usually made
up of HOF specialists with a background in ergonomics and they find it difficult
to influence important decisions since managers do not recognize their operational
competence. Attracting more operational managers to HOF courses strengthens HOF
networks by benefiting from their business profile.

EDF
At EDF, human factor consultants working in nuclear plants now operate in pairs
made up of an external human factors expert or ergonomist, and someone else with
operational experience and solid training in HOF.
56 I. Boissières

SNCF Traction
Each year, 2–3 executives from SNCF traction, the train driver division, complete the
Icsi executive master’s degree in HOF. Over time, this has created an internal HOF
network of operational staff. Today, SNCF Traction is one of the places where most
progress has been made in HOF—both at the SNCF level and at the level of French
industry. This was made possible thanks to a director who is a leader in the domain,
and the network that played a determining role in driving the deployment of HOF
initiatives internally.

4.2 Strengthen Alliances with Other Actors

Safety is not the only risk that businesses must manage. Production is fundamental
too—and HOF specialists have a long history of talking to engineering firms about
the technical details of projects in order to anticipate operational risks. Furthermore,
a poor social climate and financial problems are other major risks that threaten the
company’s survival. If HOF is going to play a role in the company’s trade-offs, it
must be better integrated into the other departments concerned.

4.2.1 Human Resources Department

An alliance with the human resources department seems easiest, probably because
this is where there are most bridges with safety and HOF.
Psychosocial risk issues are now being closely monitored by human resources
departments, often with the support of experts. It is now accepted that the root causes
of psychosocial risks are embedded in the organisation and management. Adopting
this angle of attack would not only mobilize human and organisational factors but
would do it by means of a topic linked to the organisation.
Some other issues interface easily with human resources, one of which is training.
We already highlighted the importance of managers training in HOF. Indeed, it helps
to get closer to human resources departments and allows a collaborative work on the
evolution of the management model that will serve as a basis for internal or external
training.
Another example of topics at the interface with human and organisational factors
is “just culture”. When translated at the level of an organisation, “just culture” is about
drawing up clear and fair policies in terms of recognition of good practices/sanction
of bad practices. Typically, it falls within the domain of human resources, but it is
also very fashionable in the safety world at the moment [5].
Organisational Factors, the Last Frontier? 57

4.2.2 Audit Departments

When it comes to investment decisions, any alliances must eventually extend to other
influential departments such as compliance and audit departments. This process is
just starting. As an example, a renowned human factors expert recently took part in
an audit and regulatory review [1]. Conversely, for the first time a financial controller
attended the Icsi HOF executive master in 2018.

4.2.3 Trade Unions/Regulatory Authorities

In addition to the managerial chain of command and internal managers, two other
institutional actors, union and staff representatives and regulatory authorities may be
effective partners.
Providing union representatives with HOF training represents a valuable invest-
ment because it creates internal pressure for organisational factors to be considered
at a very high level. A major French trade union, CFDT, and more specifically its
chemical energy federation, has created a major risks network and have taken HOF to
heart. They trained themselves and drew up internal policies on safety topics which
have been distributed to staff committees on all sites. Their influence has led to real
progress.

Exxon Mobil—CFDT
CFDT representatives at a large Exxon Mobil site asked for a safety culture survey to
be carried out. The analysis of this assessment led to the creation of a working group
that brought together directors, the local chemistry federation, regional officials, union
representatives, regulatory authorities, etc. It is not common to have such diverse actors
at the same table. It generated a discussion of great interest, at a very high level, about
how each organisation could help to improve industrial safety based on HOFs.

Finally, regulatory authorities are another solid ally that can, if needed, put more-
or-less friendly pressure on company managers to consider HOF. The influence
of international authorities in aeronautics is addressed in this book (see Florence
Reuzeau’s chapter, this volume). In the nuclear sector, the authority is carrying out
fundamental work into human and organisational factors on various topics including
industrial policy and subcontracting. There has not been any strong commitment so
far, but it has, at least, forced the various stakeholders in the French nuclear sector
to ask questions and eventually to agree on the way forward.
58 I. Boissières

5 Concluding Remarks: Use Short-Term Wins to Sustain

Long-Term Progress

It must be recognized, of course, that the different propositions discussed in this

chapter are difficult to implement. Therefore, it is of paramount importance to estab-
lish a strategy for implementing HOF over a longer timeframe. Like any project that
seeks to implement change, a two-step approach is needed: quick wins and long-term
structured action.

5.1 In the Short Term: HOF Quick Wins

Before going any further, HOF must be put on the agenda and win in the short term.
Here follow a few examples of quick win initiatives. A conference or a training session
for directors conducted by an excellent speaker, is an efficient way of stimulating
interest in going further. Similarly, videos or e-learning courses are good ways to
introduce the topic.

E-learning
Icsi recently developed a short, e-learning module intended for directors and managers
of a large industrial group to raise awareness about HOF. This was rapidly followed
by further training for prevention specialists and managers at a local site, and a request
from the CEO for a HOF study.

A safety culture assessment is another good way to open the door to more advanced
HOF approaches—notably as it speaks to managers who love indicators. The starting
point is safety issues, but it can go on to highlight organisational causes, such as
managerial leadership, or reward and sanction policies. The most important aspect is
that the clients should be management committees and not limited to safety managers.
These approaches are sometimes criticized by purists on the pretext that they
are not ambitious enough, or that they tell the client only what they want to hear.
However, considering them as a first step, they can be an effective way to get a
foot in the door. Once you have done that, HOF approaches can be developed and
implemented over time.

5.2 Anchoring HOFs in Companies: Key Actions

The actual issue at stake is to institutionalize HOF approaches in companies, espe-

cially in terms of organisational and strategic processes. Companies should seize
opportunities related to specific moments of their life: some steps can be particularly
Organisational Factors, the Last Frontier? 59

conducive to launching a HOF approach. One interesting example is to integrate

safety and HOF issues when the company is planning a major restructuring. Another
opportunity is the implementation of a policy of formalizing the skills managers are
expected to have. As an example, Suez has drawn up a guide for managers where
principles like “the right to make mistakes” and the need to recognize the contribution
of workers are made clear.
In a nutshell, integration and sustainability of HOF approaches in high-risk com-
panies mostly rely on going beyond the glass ceiling by reaching a critical mass of
executives open to HOF concepts, reinforcing alliances with other key sectors such
as human resources, unions and regulatory bodies, and capitalizing on quick wins to
sustain long-term progress.

References

1. R. Amalberti, La sécurité industrielle est-elle un art du compromis? Audit, risques et contrôle

(12), 25–28 (2017), https://www.foncsi.org/fr/blog/article-a-r-c-rene-amalberti
2. R. Amalberti, F. Mosneron-Dupin, Facteurs humains et fiabilité: quelles démarches pratiques
(Octares, Toulouse, 1997)
3. C. Bieder, C. Gilbert, B. Journé, H. Laroche, Beyond Safety Training: Embedding Safety in
Professionnals Skills (Springer, 2017). https://doi.org/10.1007/978-3-319-65527-7
4. I. Boissières, Une approche sociologique de la robustesse organisationnelle: le cas du travail
des réparateurs sur un grand réseau de télécommunication. Doctoral dissertation, Université de
Toulouse 2, Toulouse (2005)
5. S. Dekker, Just Culture: Balancing Safety and Accountability (Ashgate, 2012)
6. F. Dupuy, La Faillite de la pensée managériale. Lost in Management, vol. 2 (Seuil, Paris, 2015)
7. FonCSI, La sécurité, une affaire de professionnels ? Intégrer la sécurité aux compétences pro-
fessionnelles. Fondation pour une culture de sécurité industrielle (Foncsi, Toulouse, France,
2018), https://www.foncsi.org/fr/publications/collections/cahiers-securite-industrielle/securite-
affaire-professionnels
8. La sociologie sur commandes?, Sociologies pratiques (36) (2018)

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Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter’s Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Risk Management and Judicialization

Caroline Lacroix

Abstract Industrial or public transport accidents are referred to the court of justice
and often result in high-profile trials. This criminalization process raises the question
of the place of repressive justice and the issue of the debate around the judicialization
of such serious events. Beyond that, how is this penalization translated? Since the
actual conditions for the safety of at-risk activities rely on a set of factors (compliance
with norms, rules and procedures, experience of safety culture actors, etc.), how does
the judge assess fault and what place is allocated to expertise?

Keywords Judicialization · Disaster · Risks · Criminal trial · Involuntary

manslaughter · Responsibilities · Judge · Expertise

1 Introduction

Public transport, industrial and high-tech activities are likely to generate risks. Disas-
ters always lead to the same questions: why and how did it occur? Could the damage
have been avoided? What was done by those whose mission is to ensure the safety of
all? The criminal justice system often appropriates these questions in order to seek
answers, in a phenomenon known as judicialization or penalization. Judicialization
of risky activities recently featured in the news in France when, on October 31th,
2017, the Paris Court of Appeal convicted the Grande Paroisse company and its
director over the AZF disaster.

C. Lacroix (B)
Université d’Evry-Val d’Essonne – Paris-Saclay, Évry, France
e-mail: caroline.lacroix@univ-evry.fr

© The Author(s) 2020 61

B. Journé et al. (eds.), Human and Organisational Factors,
SpringerBriefs in Safety Management,
https://doi.org/10.1007/978-3-030-25639-5_8
62 C. Lacroix

2 Judicialization and Penalization

The term judicialization appeared in political discourse in the 1990s. It can thus
be understood as the expanding role of judges in monitoring compliance by certain
companies. The notion of “criminal justice” more specifically refers to “criminal-
ization” or penalization after an accident. It is understood, first, as the recourse to
criminal justice, either through the work of the public prosecutor’s office or on the
initiative of victims or associations. Penalization can also express “the reinforcement
of penal repression”, emphasizing either the propensity to question particular cat-
egories of hitherto protected citizens (local elected officials or business leaders) or
to apply criminal law to activities that had been spared it in the past. The notion of
penalization is then often used in a pejorative way and accompanied by a qualifier
reinforcing this idea, such as that of “outrageous criminalization”.

2.1 A Global Phenomenon?

Intervention by the criminal justice system is an integral part of the social response
to a disaster. Disasters have entered the criminal field and this phenomenon is neither
recent, nor uniquely French. A simple retrospective look at the legislation and prac-
tices of member countries of the European Union shows that most major transport
or industrial accidents are played out on the criminal stage in all their variations
and facets [10]. We mainly studied our close European neighbours: Germany, Spain,
Italy, Belgium, Luxembourg and Great Britain. But beyond these few examples, we
observed that other European countries do not exclude the use of criminal law in the
treatment of disasters. This was the case in Switzerland following the Überlingen
Air Collision that killed 71 people on July 1, 2002. A criminal trial was also held
in Austria in connection with the Kaprun funicular accidental fire that caused 155
deaths on November 11, 2000. Each of these states has an administrative authority in
charge of investigating the causes of the accidents. The administrative inquiry does
not exclude the separate existence of a judicial inquiry and the holding of a criminal
trial.
Contrary to popular belief, British disaster treatment is not limited to the issue of
damage repair. The United Kingdom, often cited as a counter-example of the French
criminalization movement, nevertheless tends to turn to criminal justice under the
pressure of victims’ lobbies. “Disaster Action”, was founded as a charity in 1991 by
survivors of disasters and bereaved people from the UK and overseas. They submitted
to the Royal Commission on Criminal Justice a call for radical changes in the criminal
justice system regarding the treatment of possible corporate crimes of violence. Thus,
on April 6, 2008, the Corporate Manslaughter and Corporate Homicide Act was
promulgated [1, 11, 12]. The creation of this new offence of manslaughter committed
by a corporation provided a means of accountability for very serious management
failings across an organisation. It is intended to work in conjunction with other forms
Risk Management and Judicialization 63

of accountability such as gross negligence manslaughter for individuals and other

elements of health and safety legislation.

2.2 Why this Judicialization?

There are several reasons for the attractiveness of criminal justice. Beyond proce-
dural reasons, there are sociological explanations. Criminalization of disasters and
referral to the criminal courts reflect both the social perception of risks and the social
representation of criminal justice.
In the first place, the spirit of resignation is disappearing from our modern soci-
eties. As serious accidents multiply, disasters are no longer considered fate only, but
also the result of risky human activities [2]. In one way or another, human activities
may have triggered the disaster, or it may have been caused by a lack of forecasting,
prevention or by inadequate safety management upstream. Meanwhile, the need for
safety has become fundamental. The current trend is towards an almost absolute
rejection of the inevitability of risks and the utopian affirmation of zero risk has been
erected as a principle. This increased need for protection, even precaution, has found
a resonance in law. Criminal law has a pronounced symbolic character. Our fellow
citizens firmly believe that justice is not really done until those responsible have been
given a criminal sentence.
Disasters therefore give rise to a process of dramatization of responsibilities. The
criminal judge is perceived as “the only impartial interlocutor” [13], especially when
the feeling of a “smothering of responsibilities” arises. Public opinion and victims
share the same wish to acknowledge mistakes and identify their authors. Establishing
the truth of the case is, as such, a remedy for the victim. The holding of a trial is useful
not only to the victims but also to society. It constitutes a place for confrontation and
dialogue, where searching for the veracity of the facts takes precedence even over
the strict application of the law.

2.3 The Protest

This criminalization of major disasters is not unopposed. There is no shortage of

arguments, both to justify the shortcomings of criminal law and to suggest other
ways of managing collective accidents and/or “punishments” that are less egregious
than the penal sanction. Some claim there should be sectoral criminal immunity or a
reinforced presumption of innocence in highly technical fields. It is also argued that
the fear of the criminal court results in a strict respecting of procedures, thus limiting
innovation and ultimately undermining safety.
64 C. Lacroix

2.3.1 “Just Culture” and “Blame Culture”

“Just Culture” is a culture in which front-line operators and others are not punished for
actions, omissions or decisions taken by them which are commensurate with their experi-
ence and training, but where gross negligence, wilful violations and destructive acts are not
tolerated. [8]

Successful implementation of safety regulations results in a “just culture” report-

ing environment within aviation organisations, regulators and investigation authori-
ties. This is because one element of the philosophy of “just culture” is giving the actors
sufficient leeway to allow them to share their mistakes during safety investigations
without the risk of being systematically prosecuted in criminal cases.
By contrast, a “blame culture” is a description given to an organisation in which
people are blamed for mistakes.
In this sense, the intervention of the criminal justice system in the context of
disasters would thus be an example of blame culture, unlike the philosophy of “just
culture”. Indeed, penalization of disasters would precisely lead to the refusal of
witnesses to co-operate in investigations, invoking their right to protect themselves
from criminal prosecution. This would cause a breakdown in the feedback experience.
Thus, penalization would harm safety.

2.3.2 The Case of Civil Aviation

The protest movement against penalization is particularly prevalent in civil aviation.

In 2006, the Civil Air Navigation Services Organisation (CANSO), the Royal Aero-
nautical Society in England (RAeS) and the French National Academy of Air and
Space (ANAE), adopted a resolution on the penalization of aviation accidents in
which the signatory organisations stated that they
(…) are convinced that criminal investigations and prosecutions in the wake of aviation
accidents can interfere with the efficient and effective investigation of accidents and prevent
the timely and accurate determination of probable cause and issuance of recommendations
to prevent recurrence (…) [7].

According to these professionals, most aviation accidents result from human

errors, often multiple and inadvertently committed. They declared that, in the absence
of
acts of sabotage and willful or particularly egregious reckless misconduct (including misuse
of alcohol or substance abuse), criminalization of aviation accidents is not an effective
deterrent or in the public interest. […] Increasing safety in the aviation industry is a greater
benefit to society than seeking criminal punishment for those “guilty” of human error or
tragic mistakes [7].

Such an approach found favour with the European Economic and Social Com-
mittee (EESC). In an opinion on the “Proposal for a regulation of the European
Parliament and of the Council on the investigation and prevention of accidents and
incidents in civil aviation”, this body
Risk Management and Judicialization 65

stresses the utmost importance for aviation safety of a truly independent accident investi-
gation process free from interference from the affected parties as well as from the public,
politics, media and judicial authorities. (…) EESC welcomes “Charter for just culture”
agreed by the European civil aviation social partners on 31 March 2009 [4].

Thus, the European Union seems receptive to the principle of just culture. The
term “just culture” is mentioned in the opening remarks of the 2010 regulation, as
paragraph 24 states:
The civil aviation system should equally promote a non-punitive environment facilitating the
spontaneous reporting of occurrences and thereby advancing the principle of ‘just culture’
[5].

As an extension of the European Charter for a Just Culture adopted by the social
partners of the European civil aviation sector on 31 March 2009.
But European Union law does not promote any kind of diversion. Indeed, the
assertion of the need to separate the judicial inquiry from the administrative one
in the European regulations does not, in any way, compel the abandonment of the
judicial inquiry or establish a hierarchy between these investigations. No primacy of
the administrative inquiry is affirmed. It is at best a recommendation, without binding
legal effect for the Member States.
In fact, opposing just culture and penalization is the result of a pernicious amalgam.
Just culture and a criminal trial do not occur at the same time and place. Just culture
seeks to continuously improve safety and not identify individual responsibilities.
Although it thus promotes a non-punitive atmosphere, just culture is not a system
of total impunity. Rather, it is a proactive system intended to anticipate accidents
by creating a climate of confidence favourizing the identification of any type of
information relevant for safety. However, just culture does not mean there cannot be
prosecutions when an accident occurs, notably if it has dramatic consequences.

3 The Expression of the Penalty

3.1 Foundation of Repression

The charge of unintentional crimes is used to ensure punishment via the courts of
those at the origins of catastrophes. Most disasters are caused by the offences of
manslaughter or accidental injury occurring as a result of negligence, carelessness,
inattention or the accidental destruction, damage deterioration of property through
an explosion or fire.
These terms all refer to imprudence, negligence, breaches of regulation, whose
degree of seriousness is expressed as an ordinary fault (simple negligence), charac-
terized fault (gross negligence i.e. fault exposing others to a serious danger its author
could not ignore), deliberate fault (willful misconduct i.e. breach of duty of care or
prudence).
66 C. Lacroix

Repression of imprudence, negligence liability, is a sensitive topic that has under-

gone two modifications since the entering into force of the Penal Code in 1994: first
by the law of May 13th, 1996, then by the law of July 10th, 2000. These offences
proceed from the following logic today: the degree of gravity of the fault consti-
tuting the offence is a function of the direct or indirect character of the causal link
between this fault and the damage. When the causal link is direct, simple negligence
is enough to engage the criminal responsibility of a natural person. When the causal
link is indirect, the criminal responsibility of a natural person is engaged only in the
case of willful misconduct or of gross negligence. To put it another way,
The criminal responsibility of a natural person requires a gravity of the fault inversely
proportional to the proximity of its harmful consequences [3].

The assessment of the fault must refer to the safety due diligence relative to the
circumstances and characteristics of the agent. The law of 13 May 1996 strongly
urged the criminal court to take into account the situation of the perpetrator. The
legislator then provides the judge with the elements on which the assessment must be
based: nature of the mission or functions, powers and means of the perpetrator. These
criteria invite the judge to decide on objective data. It is a question of identification,
in the conduct of the missions or the functions performed, in the exercise of the
attributed competences, as well as in the use of the devolved powers and means, all
the elements of a normal diligence. In criminal law, error is not considered a criminal
fault. Not all errors are faults. The judge is not guided by a dogmatic but by a concrete
approach, and is keen to consider the system of constraints under which safety actors
work.
The objective of the law of 10 July 2000 was to tighten the hypotheses of liability
of natural persons, indirect perpetrators, in matters of recklessness, by means of a
linkage between the causal relation and the nature of the fault. This law tends to
displace the repression towards the direct authors and the legal persons who in any
event, remain responsible for all forms of imprudence, however slight.

3.2 Typology of Responsibilities

Accidents and disasters are often caused by a combination of factors: degree of com-
pliance with norms, rules and procedures, behaviour of safety actors. The industrial
safety policy is analysed by the criminal judge, who will highlight the absence, the
inefficient implementation of this policy. The judge is also interested in human and
organisational factors in high-risk companies. By seeking the implication of human
factors, not only can compensation be obtained but also the reparation of any damage.
This power of repair of justice is most embodied in the criminal trial [9].
Today, there is a real “disasters” case law framework. The essential respect for
safety in high-risk organisations is recalled through the judgments rendered. Anal-
ysis of the various court decisions makes it possible to draw up both a typology of
the behaviours that can lead to convictions and the profile of potentially responsible
Risk Management and Judicialization 67

persons in case of a disaster. The chain of causalities extends from mere agents to
decision makers. Court decisions include the whole decision-making and safety hier-
archies of the company. These malfunctions in terms of safety can also be attributed
to the legal person. In the end, these court decisions also make it possible to build
HOF approaches to industrial safety in a large group.

3.2.1 Natural Person

In the search for multiple responsibilities, there is a real methodology implemented

by magistrates that is reflected in the form of the decisions rendered, which present
an originality in the way they are written. The most obvious manifestation of this
modus operandi appears in the ranking of potential authors, through a process of “
grouping by responsibility”.
A first group consists of the company managers and executives. These are the
persons for whom the works are carried out and who have an economic interest in
the activity at the origin of the harmful event. Imprudence or negligence committed
at the highest hierarchical level of the company is therefore sanctioned. Then there
is a second group, those who could be called the “men of art”, the entrepreneurs and
architects. They are potentially responsible since they are the ones who build and
create. Another group of officials is sometimes made up of what might be called
“safety officers”. Ultimately there is the person directly responsible for the disaster,
the one that we could call “the lamplighter”. This first link in the causal chain is often
an artisan or a worker. However, the faults committed by these immediate perpetrators
are often only evidence of much more serious mistakes committed upstream, some
of which can be blamed on public actors.

3.2.2 Legal Person

Disasters often have structural causes and the lack of safety at the origin of the drama
is sometimes the result of an explicit corporate policy. Through the implementation
of the liability of legal persons, the judge can adequately sanction the organisational
factors of a company. These safety dysfunctions can be attributed to the legal person
since the entering into force of the Penal Code in 1994, a major innovation.
The liability of a legal person may coexist with that of natural persons. It can be
engaged for a simple fault of recklessness whatever the nature of the causal link. The
decriminalization resulting from the reform of 10 July 2000 seeking to distinguish
between direct and indirect causality, has been established only for the benefit of
natural persons. Thus, the purpose is to compensate the decriminalization of natural
persons by the responsibility of legal persons.
68 C. Lacroix

4 The Judge and Expert Opinions

As stated earlier in this chapter, in France, an industrial disaster usually leads to

two different investigations, pursuing different objectives: an administrative inquiry
and a judicial inquiry. The administrative inquiry aims to quickly determine the
technical causes of the accident, to remedy them. The purpose of the judicial inquiry
is to establish the responsibilities and can therefore be a lengthier process. Let us
recall that the primary purpose of the criminal trial is not to identify a culprit, but
to respond to an incrimination (for manslaughter and accidental injury) which is
not specific to collective accidents. This investigation is also carried out in order to
explain the reasons of this accident to the victims and their relatives. And lastly, such
an investigation allows access to the judge, which is a fundamental right.
Disasters tend to be complex phenomena. Faced with multiple potential causes,
which could be either technical and/or human, the judge is obliged to call on expert
opinion to clarify the reality. The expert report ordered by the judge must be at the
service of the truth, and must enlighten the court, allow it to understand what has
happened so that it can judicially establish the potential liabilities. The truth is not
absolute and is fixed in the current state of science.
The administrative and the judicial inquiries complement each other. Both provide
elements of research that help advance safety. The administrative report is useful to
the judge. Thus, for the plane crash that occurred on March 24, 2001 in Saint-
Barthélemy, the correctional court of Basse-Terre took into account the opinion
issued by the experts of the BEA1 to render its judgment of November 15, 2006.
The issues addressed in disasters cases are mostly scientific, giving a prominent
place to expertise in contemporary criminal trials. These cases do not present any par-
ticular legal technicality, but show difficulties related to the technical fields covered.
However, the judge is often unfamiliar with these questions. Unlike investigators
and experts, they do not have any specific technical competence. Naturally, they can
undertake training in order to acquire better knowledge of the field, to understand
the various documents, to be able to ask the right questions, to be in a position not
to be manipulated by one party or the other [6].
The expert is appointed by the judge to provide them with elements within their
field of technical competence established in the sole interest of the manifestation of
the truth. In all cases, the expert’s performance must be of high quality and impartial.
The expert does not have to rule on the merits of the case. They deliver scientific
knowledge to the magistrate, but do not take part in the decision making, which falls
exclusively within the jurisdiction of the judge. It is up to the judge to decide, not the
expert. The conclusions of the experts are binding neither on the judges nor on the
parties. The criminal judge will include in their decision the elements of the report
which allow them to form a conviction. In the trial of the Mont Blanc tunnel, three
experts had been appointed to determine the causes of the fire. Two of them drew on
three private expert reports, one of which was paid for by the insurer of the truck.

1 The French Bureau of Enquiry and Analysis for Civil Aviation Safety (Bureau d’enquêtes et

d’analyses).
Risk Management and Judicialization 69

The theses proposed by the experts were rigorously analysed, weighed and compared
with the other factual elements. The investigating judge then also sought the advice
of a professor from the University of Lausanne; this last thesis was chosen because it
presented no contradiction with the facts, the chronology of the events having been
verified by simulation.
Disasters shed a different light on the relationship between magistrates and
experts. Expertise, which should be an enlightening tool, can prove to be a delaying
tool. It is necessary to be aware of the difficulties related to the limited number of
specialized experts, in fields such as aviation. This may raise the issue of the inde-
pendence of the experts, who might sometimes be linked in one way or another to
someone who is potential responsible party for the event.

5 Conclusion

Ending the criminalization of disasters could be an excessive approach and negative

for safety and security, specifically in high-risk industries. It is through criminal law
that society warns its members and stresses the essential values to be protected. The
judicial decision has an undeniable pedagogical function. It serves as a benchmark
in the interest of risk prevention, with regards to safety actors in general, beyond the
protagonists of the disaster. This approach is part of an objective to prevent the repe-
tition of disasters and encourages a better consideration of human and organisational
factors.

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(1972). https://doi.org/10.2307/3320531
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déontologie de l’expert, ed. by K. Favro, M. Lobe-Lobas, J.-P. Markus. Dalloz (2016)
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comparée du recours à la justice pour la gestion des grandes catastrophes (de type accidents
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70 C. Lacroix

11. R. Matthews, Blackstone’s Guide to the Corporate Manslaughter and Corporate Homicide Act
2007 (Blackstone Press, 2008)
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UK Ministry of Justice. Crown copyright (2007)
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(2000)

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Integrating Organizational
and Management Variables
in the Analysis of Safety and Risk

Paul R. Schulman

Abstract For decades, despite research and description of modern large-scale tech-
nologies as “socio-technical systems”, there has been little headway made in integrat-
ing research on both the socio and technical aspects of these systems. Social scientists
and engineers continue to have contrasting and often non-intersecting approaches to
the analysis of organizational factors and the physical aspects of technologies. This
essay argues that an important part of this problem has been the ambiguous and
underspecified character of the social science research concepts applied to the anal-
ysis of organization and management factors. It suggests an important opportunity
to more closely integrate social science research into the understanding of hazardous
technologies as socio-technical systems through a strategy of clarifying concepts and
definitions (such as “safety”) that allow transforming qualitative organizational and
managerial “factors” into variables to create metrics useful in the evaluation of safety
management systems. It argues also that practitioners have an important role to play
in this process. A final argument addresses the contribution that safety metrics could
make to the development of higher resolution safety management across a wider
spectrum of scales and time-frames than those currently considered by managers
and designers of socio-technical systems.

Keywords Socio-technical system · Safety · Organizational factors · Metrics

1 A Persistent Disconnect between Organizational Aspects

and Engineering

For many decades, organizational theorists, cognitive and social psychologists, polit-
ical scientists, sociologists and anthropologists and science and technology studies
specialists have researched technologies under the analytic framework of socio-
technical systems [6]. This research has provided important insights into human
factors and ergonomics [9, 29]; the psychological and anthropological aspects of

P. R. Schulman (B)
University of California, Berkeley, USA
e-mail: paul@mills.edu
© The Author(s) 2020 71
B. Journé et al. (eds.), Human and Organisational Factors,
SpringerBriefs in Safety Management,
https://doi.org/10.1007/978-3-030-25639-5_9
72 P. R. Schulman

technologies [15]; the understanding of management challenges posed by complex

technologies [5, 16, 22]; organizational and managerial dimensions of high reliability
in the operation of hazardous technologies [1, 11, 19, 20, 23]; and, more recently, the
analysis of catastrophic accidents involving complex technical systems [13, 16–18,
26]. Current accident analyses almost always identify organizational and managerial
factors as root if not proximate causes of these accidents.
Yet for all of this development the research that has explored the organizational
and managerial side of technical systems remains in the main un-integrated into
the perspectives taken by engineers and many managers in their technical designs
and organizational practices. Instead of thinking of both organizational and technical
dimensions together as part of socio-technical systems, many designers and managers
continue to think of humans and organizations as simple extensions of machines or
as sources of error in the proper operation of technical systems. Here, for example,
is one recent description of human factors engineering offered by an engineer at a
safety meeting:
If you open the plates of a circuit breaker, you will eventually have an arc. You don’t want
the electrons to arc, but no engineer would say that the electrons that formed the arc were
lazy or complacent: if you don’t want the arc, you engineer the system around the constraint.
Human factors engineering operates according to the same principle; identify the constraints
in the interactions between the employees and the workspaces, tools, and technology, and
engineer around it.1

Meant to be an argument against attributing accidents simply to operator failures,

this statement at the same time reveals a narrower engineering perspective. We know
from socio-technical systems research that human and organizational factors can
be a support to design and not only a constraint. For example, engineers may make
design errors or offer incomplete designs that humans can identify, and organizations
can correct. We know also that human behavior, despite its aggregate regularities, is
less predictable and has more variance in particular cases than the physical laws and
principles within which engineers design. Given that technologies are socio-technical
systems, we should expect engineers to incorporate human and organizational factors
more deeply into designs and not simply design “around them”.
However, integrating organizational variables into technical design processes
poses many challenges.

2 Challenges to Reconcile Them

It is not by oversight that organizational and managerial variables are often neglected,
in engineering or risk research. A range of large divides exist between organiza-
tional and management research, and the performance and risk variables typically
attended to by commercial organizations and the regulatory agencies that oversee

1 Remarks made at a “Safety en banc” event at the California Public Utilities Commission, San
Francisco, California, 19 October 2016.
Integrating Organizational and Management Variables … 73

them. Considering these divides will provide clues in developing strategies to achieve
both a research and practical integration of social and technical variables in the
understanding and practice of safety management.

2.1 Technical and Methodological Differences

Concepts and definitions of physical or mechanical variables are largely agreed-upon

and formally expressed through stipulated meanings in artificial language such as
physical descriptions or mathematical models and formulas. Most are measured along
interval scales.
Social and organizational factors such as leadership, authority, centralization,
decision-making, motivation, mindfulness, stress, culture and even “safety” itself
are grounded in concepts expressed in natural language with all of its ambiguities
and imprecision [7, 8]. These concepts are then difficult to translate into measur-
able “variables”. These organizational and managerial “variables” are often defined
as nominal categories (e.g. “high reliability” organizations) or described as oppo-
sites in binary pairs (e.g. flexibility/ridigity or centralization/decentralization) not as
continuous scales of measurement [24]. These are “factors” but not really variables.
Further, much safety and accident research is in the form of case studies which
are difficult to compare and aggregate because of their elements of uniqueness.
Often the management or organizational failures are described in non standardized
terms that do not allow comparative measurement. It is also difficult to learn about
the impact of organizational and managerial factors across cases because without
interval measures, we cannot construct regression models to determine their separate
contribution to given outputs.

2.2 Practical Challenges

Because organization and management concepts are likely to be categorical and not
easily expressible in ordinal or interval measures, it is difficult to connect analyses
of them as factors with physical and mechanical variables for purposes of model-
ing integrated relationships in affecting the safety or performance of an organization.
Also, many of the social sciences that analyze organizational factors are, unlike engi-
neering, not “design sciences” with research directed toward formal design principles
and cumulative findings to guide action and application.
74 P. R. Schulman

2.3 Political Challenges

Finally, there are political problems with employing organizational and managerial
factors in an integrated analysis of safety. Often these factors have implications that
raise the political temperature surrounding their development and use. Business orga-
nizations may resist leadership, decision-making or culture analyses because of their
potential implications for assessments of managerial competence or effectiveness.
Regulatory organizations may avoid using organizational and managerial findings
because of their vulnerability to political or legal challenges if they base regulations
and enforcements on what will be challenged as ambiguous or subjective measures
and assessments.
How, given the diverse analytic domains of physical models versus organiza-
tional factors, do we find a way to combine them in an additive way to improve our
understanding, management and regulation of safety and risk in complex technical
systems? Important risks and opportunities call for closer integration between the two
research approaches, but we are currently far away from this objective, with a mutual
ignorance, indifference, or even hostility, between researchers in these two domains.
The recent stress on safety management systems (SMS’s) by industry groups and
regulators has created growing demand for careful analysis of the implementation
of these systems and the measurement of their impact on rates of incidents and
accidents. How can we address these opportunities?

3 The Need for Clarifying Key Concepts

Among the key organizational concepts that lack clarity is the concept of safety itself,
and the relationship between safety and risk. For many designers, managers and
regulators, it is all too often assumed that “safety” is synonymous with the mitigation
of risk. “How much safety are we willing to pay for?” is often a question about
“Which specific risks are we willing to address?” But a report on aviation safety by
a group of representatives from 18 national aviation regulatory agencies concluded
the following:
Safety is more than the absence of risk; it requires specific systemic enablers of safety to be
maintained at all times to cope with the known risks, [and] to be well prepared to cope with
those risks that are not yet known [21].

Safety is about assurance; risk is about loss. Safety is in many respects a perceptual
property, “defined and measured more by its absence than its presence” [18]. It is
hard to establish definitively that things are “safe”, but much easier to recognize
specific conditions of “unsafety” retrospectively in the face of accidents. Risk is a
calculated property. Several failures or incidents can occur without invalidating a risk
estimate (two 100-year storms in consecutive years for example), but a single failure
can disconfirm the assumption of safety. This distinction also applies to a difference
between safety management and risk management. Risk management is managing
Integrating Organizational and Management Variables … 75

to probability estimations which apply to events over a large run-of-operations or

number of years. Safety management is managing down to the level of precluding a
single event in a single operation at any time [3].
Karl Weick’s definition of safety as “the continuous production of dynamic non-
events” [28] offers more promise. Here “safety” defines positive actions—identifying
potential sources and consequences of accidents (including incomplete or unforgiv-
ing technical designs), acting to prevent them, constantly monitoring for precursor
conditions that add risk or uncertainty, training and planning for the containment
of consequences of accidents if they do happen—in short safety management. As
part of this definition, it is important to understand the distinction between safety as
“dynamic non-events” and non-events in systems without careful management that
simply have so far “failed to fail”. Unfortunately, there is at present significant con-
fusion about this conceptual difference. How can we distinguish non-events that are
simply “failing to fail” from those dynamic non-events that reflect effective safety
management, without having to wait for an accident? The answer partly lies with
understanding and measuring the implementation process of safety management
systems.

4 Some Propositions about the Implementation of Safety

Management Systems

There is an important difference between implementing the structural features of

an SMS in an organization—safety officers; safety plans; formal meetings; safety
budgets; formal accountability and reporting relationships—and
• achieving a widely distributed acceptance of safety management as an integral
part of actual jobs in the organization,
• a collectively shared set of assumptions and values concerning safety (a “safety
culture”) and
• commitment to safety as part of the individual identity of personnel in an
organization.
Without wide and deep employee engagement, an SMS will simply be an admin-
istrative artifact without a strong connection to actual behaviors that link to safety-
promoting performance and safer outcomes. Further, it takes time, persistent effort,
adaptive behavior, continuous monitoring (with metrics) and correction to implement
and maintain an effective SMS.
These propositions lead us back then to the earlier essential question about deter-
mining the effectiveness of a safety management system, without having to wait for
an accident. One answer is to develop metrics to detect the full implementation and
integrity in operation of an SMS:
76 P. R. Schulman

• metrics for organizational and managerial conditions and practices—both positive

and negative—that give information about the condition of safety management
itself [10, 21, 25] and
• metrics identifying and addressing precursor management to add granularity to
safety performance assessments apart from accidents.

4.1 A Strategy for SMS Metrics Development

Retrospective measures already exist for incidents and accidents, many required by
law and regulation. The strategy of SMS metrics is to provide precursor indicators
so that the integrity of an SMS can be assessed before an accident occurs.
The precursor strategy is well illustrated by research on “High Reliability Orga-
nizations” (HROs) such as selected nuclear power plants, air traffic control organiza-
tions, high voltage electrical grids that were known for effective safety management
[11, 12, 19, 20]. This HRO research led to the recognition that a key to high reliability
is not a rigid invariance in operations and technical and organizational conditions,
but rather the management of fluctuations in task performance and conditions which
keeps them within acceptable bandwidths and outside of dangerous or unstudied
conditions [23]. Supporting this narrow bandwidth management is the careful iden-
tification, analysis, and exclusion of precursor conditions that could lead to accidents
or failures. HROs begin with those core events and accidents they wish never to expe-
rience and then analyze outward to conditions both physical and organizational that
could, along given chains of causation, lead ultimately to these accidents or to sig-
nificantly increased probabilities of them. This “precursor zone” typically grows
outward to include additional precursor conditions based on more careful analysis
and experience. These precursors are leading indicators, for these organizations, of
potential failures and are given attention and addressed by supervisors and managers.
Precursors are in effect “weak signals” to which “receptors” throughout many levels
of the organization are attuned and sensitive. In its effectiveness, a process of pre-
cursor management with metrics can impart a special kind of “precursor resilience”
to organizations [20]. With an effective safety management system, they can move
back from the approach to precursor zones quickly and still maintain the robustness
of safe performance and reliable outputs.
Metrics should reflect models of causation pertaining to safety. It should be clear
why they are important as metrics. This is promoted by the leading indicator strategy
and its underlying analysis. The identification of precursors through their potential
connection to accidents provides validity to them as metrics.
Single, high-value metrics offer perverse incentives to “manage to the metric”
or to distort the measurement process itself. Or as one manager once conceded,
“organizations will do what you inspect but not necessarily what you expect!” More
metrics with more data if possible should then be developed to cover each element
Integrating Organizational and Management Variables … 77

of a safety management system to be assessed and improve the overall reliability of

the process.
Finally, safety management metrics should be widely accepted in an organization
as important tools for learning, not as instruments of control and punishment. To
promote their acceptance, they should be the product of a joint development process
which includes regulators, organizational researchers and participants at a variety of
levels and across departments and units. Individuals at the level of task performance
often have tacit knowledge and practical insights about conditions that support or
detract from their safe performance and measurements, both direct and indirect, that
can reveal these conditions. The metrics that are developed should make sense to all
participants.

4.2 Achieving Higher Resolution Safety Management

The integration of SMS metrics with physical and engineering analyses can lead to
a more powerful socio-technical understanding of complex systems, their operation
and their risks. But coupling this understanding to safety requires also that we increase
the scale, scope and time frame of safety management itself. Here are some examples.

4.2.1 Shifts in Scale: Micro-analysis

Many precursors to system failures can be found in conditions that surround the
performance of specialized tasks. Human factors research addresses some of these—
including attention load, noise levels, ergonomic requirements that induce fatigue or
injury. More recently cognitive work analysis research has focused on micro-level
task psychology, sub-cultures and roles associated with successful task performance
relative to particular technologies or missions [14, 27]. For example, robotic surgery
has led to changes in the roles of surgeons and support groups and requires personal
resilience among surgeons to deal with unexpected issues as well as new methods
for surgical training [2].
A similar micro-analysis has also been applied to understanding the role of “re-
liability professionals” prominent in the operation of HROs [19, 20]. These are
individuals who have special perspectives on safety and reliability, cognitively and
normatively. They mix formal deductive knowledge and experiential knowledge in
their understanding of the systems they operate and manage. Their view of the “sys-
tem” is larger than their formal roles and job descriptions, and frequently center on
real-time activities. They internalize norms and invest their identity in the reliable
and safe operation of their systems. In this they are “professionals” on behalf of
reliability and safety, but not defined by particular degrees or certifications.
This degree of granularity allows the identification of SMS implementation down
to the level asserted as important in the first proposition: to be successful it must
include achieving a widely distributed acceptance of safety management and safety
78 P. R. Schulman

culture as an integral part of actual jobs down to the level of specific tasks. Micro-level
analyses can lead to metrics that can be indicators of this degree of implementation.
Note that the shift to this micro level also means an analysis of actions and behaviors
over short-time intervals, in the real-time operation of a technical system.

4.2.2 Shifts in Scale: Macro-analysis

At the other end of high resolution is the ability to analyze actions and behaviors
over larger scales and scope and with effects over considerably longer time intervals.
Here the analysis and measurement would move beyond a single organization and
its SMS to cover network safety and reliability [4]. This leads to a consideration
of safety management in relation to interconnected risks among infrastructures [20]
and across sectors.
Transmission planning for large utility grids, for example, is a process that can
cut across large populations and across nations. Generally, it has to look ahead over
a 5–10-year time frame to anticipate electricity demand patterns and new generation
technologies as well as to encompass the time it takes to translate plans into actual
construction of new transmission lines and capacity. But as one grid management
analyst noted: “What goes on in planning eventually ends up in operations.” That
is, activity and management on this time frame will eventually impose itself on
day-to-day real-time grid operations.

4.2.3 Elongated Time Frames

Many interconnected risks span an international and even a global scale and an inter-
generational time-frame. Problems such as global climate change and sea-level rise
are slow-motion issues which convey inter-generational risk. These safety manage-
ment problems will need to be addressed across many different sectors on a global
scale over the next 20–50 years.
Similarly, long term effects of nuclear waste disposition and storage are safety
management challenges. But they require planning and possibly ongoing safety man-
agement attention over decades, if not centuries. We currently pay attention to plan-
ning for reliability of infrastructures, but we will have to pay more attention, with
metrics, to reliable planning itself as a management process. Larger scales and longer
time frames also require that safety management be supported by social policy and
regulation.
Analyses of safety management across these scales and time frames can lead to a
higher resolution additive understanding of organizational and managerial factors in
safety and reliability, running from macro to micro levels of analysis over long- and
short-term-time frames. Then we can analyze the safety interconnections between the
levels and time scales—how what happens or does not happen at one level of planning
and management scale can affect the safety of operating conditions at another. How
culture, roles and psychology surrounding individuals in their specific tasks can
Integrating Organizational and Management Variables … 79

Fig. 1 A higher resolution safety management framework

affect their performance and how this performance in turn impacts system safety
well beyond that task. The following figure (see Fig. 1) is one integrated illustration
of the scale and scope of organizational and managerial attention in relation to the
time frame needed for action to promote safety.

5 Conclusion

This paper began with an expression of disappointment over the lack of progress in
integrating organizational and management variables with physical models into our
understanding of technologies as socio-technical systems.
It concludes with the recognition that it will take a large and persistent R&D effort
to achieve the integration of organizational and managerial variables as safety man-
agement metrics into the physical analysis of technical systems. But an integrated
understanding of socio-technical systems, across scales, scopes and time, could sig-
nificantly add to our understanding of how to manage and ultimately design them
for increased safety.
80 P. R. Schulman

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16. C. Perrow, Normal Accidents (Princeton University Press, Princeton, 1999)
17. President’s Commission on the Accident at Three-Mile Island, U.S. Government Printing
Office, Washington, D. C. (1979)
18. J. Reason, Organizational Accidents Revisited (CRC Press, Boca Raton, 2016)
19. E. Roe, P. Schulman, High Reliability Management (Stanford University Press, Stanford, 2008)
20. E. Roe, P. Schulman, Reliability and Risk: The Challenge of Managing Interconnected Critical
Infrastructures (Stanford University Press, Stanford, 2016)
21. Safety Management International Collaboration Group, Safety management system evaluation
tool (2013), https://www.skybrary.aero/bookshelf/books/1774.pdf
22. S. Sagan, The Limits of Safety (Princeton University Press, Princeton, 1995)
23. P. Schulman, The negotiated order of organizational reliability. Adm. Soc. 25(3), 353–372
(1993)
24. S. Stevens, On the theory of scales of measurement. Science 103, 677–680 (1946)
25. U.L., Using leading and lagging safety indicators to manage workplace health and safety risk.
Underwriters Laboratories (2013)
26. D. Vaughan, The Challenger Launch Decision (University of Chicago Press, Chicago, 2016)
27. K.J. Vicente, Cognitive Work Analysis (Lawrence Erlbaum Associates, Mahwah, 1999)
28. K. Weick, Organizing for transient reliability: the production of dynamic non-events. J.
Contingencies Crisis Manag. 19, 21–27 (2011)
29. K.M. Wilson, W.S. Helton, M.W. Wiggins, Cognitive engineering. Cogn. Sci. 4(1), 17–31
(2013)
Integrating Organizational and Management Variables … 81

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter’s Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter’s Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Turning the Management of Safety Risk
into a Business Function: The Challenge
for Industrial Sociotechnical Systems
in the 21st Century

Daniel Mauriño

Abstract Since World War II, the history of safety in industrial sociotechnical sys-
tems has evolved through different paradigms. From the days of “operate-break-fix-
operate”, through system safety, human factors, organizational factors and “cognition
in the wild”, engineering and social disciplines have contributed to the safety of indus-
trial systems that require close interaction between people and technology to achieve
their production goals. Yet, regardless of paradigms, disciplines or industries, the
hierarchical status of safety has remained largely unaltered: safety may be claimed
to be the first priority of industrial systems, but boardrooms agendas seldom reflect
that assertion. The contention in this chapter is that if safety is to elevate its status
within other functions in industrial systems, if it is to become an out-of-the-ordinary
topic on boardrooms agendas, it must contribute to the management of overall orga-
nizational risk, along the same lines and at the same level as the financial, legal,
quality, human resources or any other business functions of the organization. The
chapter provides a conceptual outline of the building blocks of a system that would
contribute towards such an end. Central to this system is its capability to support
an evidence-based allocation of prioritized safety resources, as well as the use of
procedures and a language that parallels the procedures and the language of other
business functions. The chapter builds on and mostly discusses the experience of
the aviation industry, because it is the sector that has, until now, taken a lead in the
direction proposed. Nevertheless, it is asserted that the notion of the management of
safety as a business function is transversal to all industrial sociotechnical systems.

Keywords Accident risk reduction · Business management · Human factors ·

Management · Risk · Safety management · Safety risk management ·
Sociotechnical systems · System safety

D. Mauriño (B)
Independent Safety Management Consultant, Milton, ON, Canada
e-mail: daniel.maurino@gmail.com

© The Author(s) 2020 83

B. Journé et al. (eds.), Human and Organisational Factors,
SpringerBriefs in Safety Management,
https://doi.org/10.1007/978-3-030-25639-5_10
84 D. Mauriño

1 Introduction

The proposal to turn the management of safety (or safety management) into a business
function hinges around three key ideas that apply regardless of the industry and across
the typical range of conditions under which industrial sociotechnical systems operate
and deliver their services.
First, safety must evolve from its historical role—without abandoning it –, which
was almost exclusively focused on accident risk reduction, and broaden into a func-
tion that contributes to the overall risk management of the organization. To this end,
it becomes necessary to develop processes and activities for the management of
safety risk (or safety risk management) that mirror the processes and activities for
the management of risk in other functions that support overall risk management.
Second, it is almost impossible for industrial systems to address all the safety
concerns that they face during their service delivery operations: the cherished notion
of zero accidents is closer to an idealized concept than to a realistic possibility.
Therefore, industrial systems must prioritize safety concerns through the anticipated
management of safety risk, in a manner consistent with the prioritization of risk of
other business functions, rather than “run after the last accident” while requesting,
after the fact, limitless resources to avoid repetition.
Third, involvement in decision-making regarding the management of safety risk
must move up the organizational ladder—as does involvement in decision-making
regarding the management of risk in other business functions—from the subject
matter expert level to executive leadership level.
The chapter starts by providing a brief account of the disciplines that nurtured
safety in industrial socio-technical systems after World War II. This is because a
proposal based on evolutionary change is essential, given the documented abhorrence
for revolutionary change of socio-technical systems. Following this account, the
chapter develops a conceptual proposal for a system for the management of safety risk
as a business function, and briefly discusses—as the cornerstone of the proposal—a
particular perspective on the notions of management and risk. The chapter lastly
discusses the three key ideas outlined above, as the vehicles turn—in practice—the
management of safety into a business function.

2 Brief Historical Background

2.1 System Safety

System safety was the first post-World War II contributor to industrial systems safety
and remains, after more than 60 years, the reference for technological industrial
design regardless of industry [3]. Two footnotes regarding the potential of system
safety to contribute to the management of safety as a business function are relevant
Turning the Management of Safety Risk into a Business … 85

here. First, system safety was conceived exclusively for the improvement of tech-
nical systems (an aircraft, ship, car, engine, pump, etc.). Second, within the strong
engineering credo of system safety, the human operator is considered a liability,
due to the potential for human mishandling of technology during service delivery
operations.

2.2 Human Factors

Human factors joined system safety in contributing to industrial systems safety circa
1970s [6]. Three footnotes are relevant here. Human factors was conceived for appli-
cation to socio-technical systems, of which industrial systems are prime examples.
Second, from the cognitive perspective, human factors considers the human operator
an asset, due to the ability of humans to “think on their feet” and provide responses
to operational situations unforeseen by design and planning [2, 5, 10]. Third, from
the organizational perspective, human factors considers human error as a symptom
of deficiencies in the architecture of the system rather than the cause: operational
error is an indication of problem(s), but not the problem(s) itself [8].

2.3 Business Management

Until business management appeared in industrial safety, some twenty-five years ago,
the paradigmatic safety goalpost had been the absence of low frequency, high-severity
events: safety was viewed as freedom from accidents. Under business management
thinking applied to safety—“one cannot manage what one cannot measure”—it is
necessary to prospect higher frequency, lower severity events as alternative safety
goalposts that provide the larger volume of data necessary for the development of
safety risk management information. Business management applied to safety also
leads the organization to assign sense to the safety dollar: is the safety return worth
the resources invested for its achievement?
Two final footnotes are relevant here. It is intrinsic to business management that the
organization must develop multiple sources of information acquisition during service
delivery operations. Accident investigation as the sole source of safety data does not
generate the volume (or the calibre) of information necessary for the management
of safety risk. Second, business management applied to safety does not aim at an
“ideal” safety status (safety first, zero accidents, safety is everybody’s business, safety
starts at the top, and so forth), but at service delivery operations under conditions of
“acceptable” (i.e. controlled) safety risk.
86 D. Mauriño

3 A System for the Management of Safety Risk

as a Business Function

3.1 A Conceptual Proposal

The proposal for a system for the management of safety risk as a business function
builds upon the integration of aspects from system safety, human factors and business
management.
From system safety, the proposal retains the two basic entities of hazard and
risk and introduces a third entity: potential consequence (the anticipated outcome
of hazards). This provides guidance for the capture of high frequency, low severity
safety concerns in a volume appropriate to the need of “measuring what must be
managed,” and to support the evaluation of the safety concerns for prioritization
purposes.
From human factors, the proposal retains organizational psychology (the organi-
zational accident) and cognitive psychology (human performance as an asset rather
than a liability) as central linchpins. These provide guidance to define the context
where the capture of information on hazards takes place and allows a perspective of
operational human performance vis-à-vis features of the workplace that may neg-
atively affect it. From this perspective, it is essential not to lose sight of the fact
that “work as imagined” (procedures) and “work as delivered” (practices) are fre-
quently asymmetrical. Since operations are delivered according to practices and not
procedures, the implications of this asymmetry in industrial systems service delivery
operations safety become clear [9].
The integration of elements from system safety and human factors covers two of
the central activities in the management of safety risk as a business function: hazard
identification and analysis and safety risk evaluation and mitigation.
From business management, the proposal retains the three basic elements of orga-
nizational control theory (direction, supervision and control) to monitor the effective-
ness of the mitigations implemented for the management of safety risk. The result
is the third central activity in the management of safety risk as a business func-
tion: safety performance monitoring using safety performance indicators and safety
performance targets.
Interfacing hazard identification and analysis with safety risk evaluation and mit-
igation and with safety performance monitoring, conforms to a process known as
safety risk management, which is the conceptual basis for the management of safety
as a business function [7].

3.2 The Terms Management and Risk

A conceptual proposal for a system for the management of safety risk as a business
function cannot avoid a discussion of the terms management and risk. These terms
Turning the Management of Safety Risk into a Business … 87

are common currency in the safety language of industrial systems; yet, they are often
applied in a colloquial sense.
The term management derives from the early Italian verb maneggiare, meaning,
“to ride a horse with skill” [4]. At face value, the meaning appears as an irrelevant
metaphor. However, riding a horse with skill requires directing, supervising and con-
trolling the horse so that it does what the rider wants in order to reach the intended
destination. From this angle, the implications of the etymology of the term in provid-
ing direction, supervision and control to safety risk management activities become
explicit.
The term risk also derives from an early Italian verb: risicare, meaning, “to dare”
[1]. As the etymology of the term suggests, risk is not about fate but about decision
and choice: we decide to accept or reject the choice(s) resulting from the evaluation
of risk.
Combining the two terms into a single clause—risk management—and drawing
from their respective etymologies, it is proposed that risk management involves dar-
ing to make decisions about choices that provide direction, supervision and control
to specific activities. Extending this to safety, safety risk management involves daring
to make decisions about choices that provide direction, supervision and control to
safety activities.
Risk is not limited to safety; risk may be related to finance, legal, economics,
quality or any other function of an industrial system. In fact, the term enterprise risk
has been coined to encompass the overall risks faced by an industrial system, and to
underline the importance of their joint management.
The joint management of overall enterprise risk—enterprise risk management—
is important because it ensures the continued viability of an organization. Thus, the
management of safety risk through a dedicated management system goes beyond
accident risk prevention, to become a contributor to organizational viability. Safety
risk management is therefore the essential business function to be delivered by the
safety structure of the industrial system to support enterprise risk management.

4 Three Key Ideas for a System for the Management

of Safety Risk as a Business Function

4.1 Safety beyond Accident Risk Reduction: Direction

and Supervision

The first key idea for operationalizing a system for the management of safety risk as
a business function focuses on the need to broaden the scope of the safety function in
industrial systems and acknowledge the difference between accident risk reduction
(the term commonly used by industrial systems is accident prevention) and safety
risk management. This is a difference that goes beyond semantics.
88 D. Mauriño

Accident risk reduction/accident prevention involves activities to avoid experi-

encing low-probability/high severity negative outcomes. The link between accident
risk reduction activities and the avoidance of accidents is explicit and direct.
Safety risk management involves activities that generate information to support
the choice of senior leaders regarding priorities in the allocation of resources to
address potential consequences of hazards. The link between safety risk management
activities and the avoidance of accidents is implicit and indirect.
There is a likelihood that safety risk management may prevent accidents. This
would be a by-product—as opposed to a goal—of safety risk management. Accident
risk avoidance is the province of safety programmes. Safety risk management is the
vehicle for a system for the management of safety risk as a business function. Safety
programmes are resourced, or not resourced, as a function of choices in the prior-
ities regarding the allocation of resources that result from safety risk management
information.
It is worth emphasising this point: safety risk management is about decisions on
priorities regarding the allocation of resources (including the decision to not allocate
resources) to contribute to the management of overall enterprise risk.
Applying the three basic elements of organizational control theory to the manage-
ment of safety risk just as they apply to the management of financial, quality, human
resources or any other risk within an industrial system provides:
• Direction, by setting risk management targets; in this case, safety performance
targets;
• Supervision, through the collection and analysis of information regarding risk
monitoring indicators; in this case, safety performance indicators; and
• Control, through the allocation/re-allocation of resources based on the analysis of
information, to achieve the risk management targets that have been set; in this case,
monitoring progress of safety performance indicators towards their associated
safety performance targets.
In developing safety performance indicators and safety performance targets, there
should be less focus on the use of outcomes and more emphasis on the parameters
that are the forerunners of the outcomes. The following example is taken from the
aviation industry.
Aircraft must respect what is known as a “stable approach” to landing. Unstable
approaches may lead to a number of undesirable outcomes and are a quintessential
safety concern in aviation.
To conform to stable approach criteria, aircraft must be within specified posi-
tion(s) of the flight controls and the landing gear, at specified indicated speed(s), and
at specified engine(s) regime(s)—all this encompassed under the term “configura-
tion”—at fixed points along the approach to the runway. These fixed points typically
are 10 miles from touchdown; the final approach fix (or FAF), and the point in which
the flight crew must decide whether to continue to land or initiate another approach
if the approach is not stable (“the window”).
The safety risk management activities involved in this example would be:
Turning the Management of Safety Risk into a Business … 89

• Implementing mitigations that aim at ensuring that flight crews and aircraft meet
the requirements to conform to stable approaches
• Providing direction for monitoring the effectiveness of mitigations by establishing
safety performance targets
– Expected aircraft configuration at 10 nautical miles from touchdown;
– Expected aircraft configuration at the FAF; and
– Expected aircraft configuration at “the window”.
• Providing supervision for measuring the effectiveness of mitigations by establish-
ing safety performance indicators
– Aircraft configuration values at 10 nautical miles from touchdown;
– Aircraft configuration values at the FAF;
– Aircraft configuration values at “the window”.
• Providing control by allocating/reallocating resources if measurement of the safety
performance targets indicates that implemented mitigations fall short of achieving
the expected results (expected aircraft configuration values are not met). Control
is further discussed in an example from another industry in the following section.
It must be emphasized that safety risk management involves the monitoring and
measurement of the parameters (the configuration values) underlying proposed mit-
igation(s), as opposed to monitoring the outcome that the mitigation(s) seeks to avoid
(unstable approaches).
Monitoring parameters will generate a larger amount of data than monitoring out-
comes, and capture information regarding the success of the mitigation(s) (number
of flights that do meet stable approach criteria) rather than the failure of the miti-
gation(s) (number of flights that do not meet stable approach criteria). Comparing
rate of success to rate of failure allows a relationship to be established between
safety achievement and the investment required for the safety achievement (return
on investment). Data about failure (unstable approaches) would make it difficult to
establish this relationship.

4.2 The Prioritization of Safety Concerns: Control

The second key idea for developing a system for the management of safety as a
business function refers to “rationing” always-finite resources, since no organization
has enough resources to address all the potential consequences of hazards. This
responds to the third element of organizational control theory: control.
The first step in “rationing” involves evaluating the safety risk of the potential
consequences of hazards identified. Once potential consequences are safety-risk pri-
oritized, implementation of safety risk mitigations according to determined priorities
follows. As part of the prioritization, some of the potential consequences may be
ignored due to resource availability, but this would be a data-supported choice.
90 D. Mauriño

Fig. 1 Activities evaluated for safety risk

Mitigation does not automatically mean solution, and resources allocated to miti-
gations that do not result in the expected solutions are wasted resources that could be
re-allocated for more efficient purposes (no return on investment). Thus, the second
step in the “rationing” involves monitoring the effectiveness of mitigations—as close
to real time as possible—to ensure the mitigations are delivering the expected safety
performances (return on investment).
The aeronautical example in the previous section applies here; however, for
broader illustrative purposes, a further example borrowed from the oil industry fol-
lows. The example also supports the assertion in this chapter that the management
of safety as a business function travels quite well across inter-industry boundaries.
Figure 1 depicts the main safety concerns specific to an operation, risk-evaluated
and prioritized according to potential severity of the consequence of the concern.1
The nature of the safety concerns is irrelevant for the purpose of the example; what is
relevant is that only 10% of the total resources available to address all safety concerns
in the list were allocated to address the two with the greatest potential severity (the
two top bars), meaning this operation allocates 90% of its budgeted resources to
addressing lesser safety concerns. This does not necessarily mean ineffective accident
risk reduction activities (i.e. ineffective accident prevention), but rather that control
of safety resources (safety risk management) is not as effective as it could be. Control
of safety resources not based on safety risk management may lead an organization
to invest in activities that do not bring return on investment. This is often the case
when resource allocation is based in opinion instead of data.

1 English translation of this graph is irrelevant since the activities it refers to are very industry-
specific. What this graph aims to convey, is the prioritization of the activities according to their
safety risk evaluation.
Turning the Management of Safety Risk into a Business … 91

Fig. 2 Standard observation card

Moving on with the example, Fig. 2 illustrates an observation card, typical of

many industries, used to routinely monitor workplace safety practices and condi-
tions. Observation cards reflect—in theory—organizational expectations of where
the most severe incidents are likely to occur during service delivery operations. In
both cases illustrated above, the contents of the card and the budget allocation to
risk prevention were based on personal experience, anecdotal evidence, history and
92 D. Mauriño

so forth, and not on data. Indeed, in the example of the safety card above, closer
inspection showed that nothing related to the two actions with the highest severity
were reflected in the aspects to be observed. Since observations are labour-intensive,
this raises questions not only related to safety, but also related to the allocation (or
rather the mis-allocation) of resources.

4.3 Elevating Safety to the Boardroom

The third key idea for operationalizing a system for the management of safety risk
as a business function addresses the need to elevate safety to the boardroom. This is
because decisions on risk evaluation are purely technical and belong at the subject
matter expert level; decisions on risk mitigation are financial, legal and administra-
tive because risk mitigation involves financial, legal and administrative considera-
tions (and costs). As such, decisions on risk mitigation belong—ultimately—in the
leadership levels.
Attempts to insert safety into the routine agenda of the leadership from the acci-
dent prevention angle are self-defeating, because risk management is part of the
procedures and the language of leadership; accident prevention is not. As the history
of industrial systems shows, few things are more counterproductive than trying to
“force safety down the throat” of leadership, trying to capture its attention by resort-
ing to the moral and ethical undertones assigned to safety or, even worse, trying to
turn leadership into safety experts.
As long as accidents do not occur, safety is not part of the routine agenda of
the leadership, and rightly so: why and how could the leadership address something
that has not happened? How can absence be risk-evaluated and risk-managed? An
accident is to safety what bankruptcy is to finance. No financial officer would consider
reporting financial success by stating that the organization has avoided bankruptcy.
Yet, safety officers consistently report safety success by stating that the organization
has avoided accidents.
The proposal of the chapter in this respect is simple and straightforward: if the
safety function is to be effectively elevated to the boardroom, if leadership is to be
encouraged into regularly making decisions regarding safety risk mitigation as part
of its agenda, safety must take some distance from accident prevention and observe
the procedures and the language of safety risk management. This will provide for a
natural forum for safety—alongside finance, legal, quality, human resources or any
of the other functions—in the organization’s senior governance decision-making
structure.
Are there significant roadblocks to the management of safety as a business func-
tion? Only two are envisioned. One relates to traditional mindsets among safety
practitioners who mostly have engineering backgrounds, and how to modify deeply-
rooted safety practices. The “changing of the guard” regarding professional demo-
graphics and the education they are receiving will facilitate removal of this poten-
tial roadblock. The other relates to data storage and retrieval. Only aviation has an
Turning the Management of Safety Risk into a Business … 93

industry-wide accepted taxonomy, and data management without taxonomy may

quickly become a nightmare. By no means an insurmountable roadblock, it only
requires minds and subject matter expertise to come together, while remembering
that consensus regarding taxonomy definition is labour-intensive and it takes time,
as the experience of the aviation industry indicates.

5 Conclusion

Since World War II, industrial safety has progressed under the guidance provided by
three unconnected disciplines: system safety, human factors, and business manage-
ment. To overcome perceived shortcomings in doing more of the same with more
intensity in pursuing industrial safety in the 21st Century, the three disciplines must
converge towards a point of confluence. The result of this confluence would be, in
practice, the vehicle for the operationalization of the management of safety risk as a
business function. The challenge ahead becomes the coordinated integration of the
three disciplines into a coherent whole. This chapter has presented an outline of the
integration.

References

1. G. Alston, How Safe Is Safe Enough? (Ashgate, Aldershot, 2003)

2. R. Amalberti, La conduite de systèmes à risques (Presses Universitaires de France, Paris, 1996)
3. C.A. Ericson II, The four laws of safety. J. Syst. Saf. 2007, 8–11 (2006)
4. C. Hood, D.K.C. Jones, Accident and Design—Contemporary Debates in Risk Management
(UCL Press, London, 1996)
5. E. Hutchins, Cognition in the Wild (The MIT Press, Cambridge, 2000)
6. International Civil Aviation Organization, Human Factors Training Manual. ICAO (1998)
7. D. Mauriño, Why safety management systems? International Transport Forum
(ITF)/Organization for Economic Cooperation and Development (OECD) (2017), https://
www.itf-oecd.org/safety-management-systems-roundtable
8. J.T. Reason, Managing the Risks of Organizational Accidents (Ashgate, Aldershot, 1997)
9. S.A. Snook, Friendly Fire (Princeton University Press, New Jersey, 2000)
10. D.D. Woods, S. Dekker, R. Cook, L. Johannesen, N. Sarter, Behind Human Error (Ashgate,
Aldershot, 2010)
94 D. Mauriño

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter’s Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter’s Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
The Strategic Agility Gap: How
Organizations Are Slow and Stale
to Adapt in Turbulent Worlds

David D. Woods

Abstract How can organizations cope with accelerating change in more complex
worlds? The growth of capabilities produces expanded scales of operation, extensive
interdependencies, new vulnerabilities, and puzzling failures. The result is the strate-
gic agility gap where organizations are slow and stale in recognizing changing risks
and fall behind the pace of change. The chapter addresses what factors drive the gap
and what adaptive capabilities allow organizations to flourish in the gap. The result is
a new paradigm for continuous adaptability illustrated in web-powered enterprises.

Keywords Resilience engineering · Strategic agility gap · High reliability

organizations · Complex adaptive systems (Human) · Fluency law · Web
operations · Continuous adaptability

1 Introduction

Organizations face the challenge of how to adapt to the increasing pace of change
in more complex worlds. The growth of capability brings rapid changes to society
as new opportunities arise, complexities grow, and new threats emerge. The impact
of deploying new technological capabilities has led to expanded scales of opera-
tion, dramatic new capabilities, extensive and hidden interdependencies, intensified
pressures, new vulnerabilities, and puzzling failures.
Can organizations keep pace with the trajectory of change? Experience across
industries indicates organizations are slow and stale in adapting to new threats, as
well as to seize new opportunities. Surprising failures and service outages are regular
occurrences in the news. One example is the threat of ransomware which offsets the
value brought by new levels of computerized connectivity. This threat arose quickly
with attacks on hospitals in 2016/2017 (CedarSinai/Medstar in US; Wannacry attack
in the UK). Computer connectivity provided value that led to increased reliance,
but also provided means for others to hijack the capability for their purposes. As

D. D. Woods (B)
The Ohio State University, Columbus, USA
e-mail: woods.2@osu.edu

© The Author(s) 2020 95

B. Journé et al. (eds.), Human and Organisational Factors,
SpringerBriefs in Safety Management,
https://doi.org/10.1007/978-3-030-25639-5_11
96 D. D. Woods

Strategic
Agility
Gap
Quality / Impact

Accelerated Strategic
Trajectory Agility
Pace of societal change/needs

Current trajectory

Now

Past Future

Technical Progress
Fig. 1 The strategic agility gap

capability grows to improve performance on some criteria, interdependencies become

more extensive and produce surprising anomalies as the systems also become more
brittle.
The strategic agility gap is the difference between the rate at which an organization
adapts to change and the rise of new unexpected challenges at a larger industry/society
scale. It is a mismatch in velocities of change and velocities of adaptation (Fig. 1).
Can organizations learn how to offset changing risks before failures occur? Can
organizations build capabilities to be poised to adapt to keep pace with and stay
ahead of the trajectory of growing complexity? The chapter addresses what drives
the strategic agility gap and what adaptive capabilities organizations need to flourish
in the gap.

2 Organizations in the Gap—Synchronizing Activities

to Keep Pace with Cascading Events?

The gap arises as the pace of change accelerates reshaping the risks and opportunities
organizations face. Organizations need the ability to adapt as challenges change. But
experience shows organizations generally are slow and stale to respond to challenge
events [13]. Consider high frequency computerized financial trading. Some people
The Strategic Agility Gap: How Organizations … 97

recognized that a relative speed advantage in trading was a special resource that
could be leveraged. They invested tens of millions of dollars for slivers of relative
speed, while others were oblivious to the changes underway. The speed advantage
made possible through computerization led to wholly new forms of trading, such
as ‘dark pools’, adapted to make large profits. The financial advantage of speed
arose from other effects of the shift to computerized trading: expanding volumes
and the multiplication of stock exchanges available. New scales of operation and
speed emerged. Everything became software dependent: regulatory changes, external
competitive changes, internal changes to better compete, all were changes in software.
The growth trajectory resulted in new relationships, new scale of operations, new
interdependencies, new tempos of operation, accompanied by new risks which were
difficult to see ahead.
This trajectory of growth means disturbances/challenges can grow and cascade
faster than responses can be decided on and deployed to effect. To overcome this
risk requires enhancing the ability to anticipate and build a readiness-to-respond in
advance of challenge events. To fail to anticipate means a new response has to be
generated during the challenge event—greatly increasing the risk of failing to keep
up with the tempo. This aspect of the demand trajectory in Fig. 1 means organizations
need to coordinate and synchronize activities over changing tempos, otherwise deci-
sions will end up slow and stale. This occurred dramatically in a case of “runaway”
automation in financial trading.1

2.1 Knight Capital Collapse 2012

As one part of the organization deployed new software in order to take advantage
of changes in the industry, the rollout did not go as expected, producing anomalous
behavior. The team tried to rollback to the previous software configuration as is
standard practice for reliability. But the rollback produced more anomalous behavior.
The roles responsible for the digital infrastructure struggled to understand what
produced the anomalies and why normal attempts to recover had failed. Meanwhile,
automated trading continued.
It took time before the team decided to involve upper management—to say the
IT team did not understand the problem, were unable to block the cascade of effects,
and the only action available was to stop trading. As upper management became
informed and authorized a trading stop, it was too late—automated trading had gone
on so long the company was, for all practical purposes, bankrupt from an untenable
market position.

1 See https://michaelhamilton.quora.com/How-a-software-bug-made-Knight-Capital-lose-500M-

in-a-day-almost-go-bankrupt and https://www.kitchensoap.com/2013/10/29/counterfactuals-

knight-capital/.
98 D. D. Woods

The case illustrates risks for organizations in the strategic agility gap. First, small
problems can interact and cascade quickly and surprisingly given the tangle of depen-
dencies across layers inside and outside the organization. Second, as effects cascade
and uncertainties grow, multiple roles struggle to understand anomalies, diagnose
underlying drivers, identify compensatory actions. Third, difficulties arise getting
authorization from appropriate roles to make non-routine, risky, and resource costly
actions, while uncertainty remains. Fourth, all of the above take effort, time, and
require coordination across roles. Meanwhile, time pressures grow as situations
deteriorate. Fifth, when critical replanning decisions require serial communication
vertically through the levels of the organization, responses are unable to keep pace
with events. The case illustrates the need to synchronize activities across roles and
layers of the organization as tempo varies.

2.2 Coping with Hurricane Sandy 2012

Other cases highlight how to be poised to adapt. Deary examined how a large trans-
portation firm learned to reconfigure coordination across roles and layers when events
with unpredictable risky demands occurred. He observed how the organization used
these techniques during hurricane Sandy [7]. To adapt effectively, the organization:
• re-prioritized over multiple conflicting goals,
• sacrificed cost control processes in the face of safety risks,
• valued timely responsive decisions and actions,
• coordinated horizontally across functions to reduce the risk of missing critical
information or side effects when replanning under time pressure,
• controlled the cost of coordination to avoid overloading already busy people and
communication channels,
• pushed initiative and authority down to the lowest unit of action in the situation to
increase the readiness to respond when unanticipated challenges arose.
Upper management developed mechanisms for this shift prior to particular challenge
events. As hurricane Sandy approached New York, temporary teams were created
quickly to provide timely updates (weather impact analysis teams). In temporary local
command centers key personnel from different functions worked together to keep
track of the evolving situation and re-plan. The horizontal and vertical coordination
possible through these centers worked to balance the efficiency-thoroughness tradeoff
in a new way for a situation that presented surprising challenges and demanded
high responsiveness [10]. The firm used mechanisms to expand/speed coordination
across roles in order to match the tempo of events, even though these mechanisms
sacrificed economics and standard processes. These mechanisms existed because this
firm’s business model, environment, clientele, and external events regularly required
adaptation as surprises were a normal experience.
The Strategic Agility Gap: How Organizations … 99

2.3 Contrasting the Cases

The cases reveal how to be poised to adapt. Simply working to plan is not suffi-
cient to handle exceptions, anomalies, and surprises, regardless of the contingencies
built in the standard practices [14]. Anticipation and initiative are necessary in order
for systems to adapt given the potential for difficulties to cascade [9]. When a unit
confronts situations that challenge plans, delays are inevitable if the unit must first
inform others and then wait for new instructions before initiating a response. In this
reactive mode for revising plans in progress, performance is guaranteed to be slow
and stale with limited ability to keep pace with change, as in the Knight Capital
case. In contrast, the organization facing hurricane Sandy shifted to value respon-
siveness, push initiative down to units of action, and invoke mechanisms for timely
coordination across roles as events unfolded.
In both cases multiple tempos of operation went on in parallel—which is basic for
adaptive systems in complex worlds. When the connections across the mixed tempos
were serial, responses lagged events. Facing hurricane Sandy, the other organization
changed how it functioned to coordinate activities across the mix of tempos—which
changed unexpectedly. From facing surprises in the past, the varying roles/levels
had opportunities to exercise their coordinative ‘muscles,’ even though this specific
event presented unique difficulties. In the strategic agility gap, the challenge for
organizations is to develop new forms of coordination across functional, spatial, and
temporal scales—otherwise organizations will be slow, stale and fragmented as they
inevitably confront surprising challenges.

3 Systems Are Messy

The cases described to illustrate the strategic agility gap, highlight how systems are
messy, fundamentally [1, 14]. All systems are developed and operate given finite
resources and live in a changing environment [5]. As a result, plans, procedures,
automation, all agents and roles are inherently limited and unable to completely cover
the complexity of activities, events, demands, and change. All systems operate under
pressures and in degraded modes. People and operations adapt to meet the inevitable
challenges, pressures, trade-offs, resource scarcity, and surprises. To summarize the
point vividly, Cook and Woods [6] use a coinage from the American soldier in
WWII: SNAFU is the natural state of systems—where SNAFU, stands for Situation
Normal All F_ _ _ ed Up. With SNAFU normal, SNAFU catching is essential—
resilient performance depends on the ability to adapt outside of standard plans as these
inevitably break down. SNAFU catching, however technologically facilitated, is a
fundamentally human capability essential for organizational viability [15, 16]. Some
people in some roles provide the essential adaptive capacity for SNAFU catching,
though this may be local, underground, and invisible to distant perspectives [12].
100 D. D. Woods

The synthesis presented here begins with the recognition that all organizations
are adaptive systems, consist of a network of adaptive systems, and exist in a web
of adaptive systems—i.e., the resilience engineering paradigm. All human adaptive
systems make trade-offs to cope with finite resource and all live in a changing world.
The pace of change is accelerated by past successes, as growth stimulates more
adaptation by more players in a more interconnected system. The scale and pace of
change grow so that synchronizing over more roles at multiple tempos gets harder.
The strategic agility gap captures the dynamic whereby growing capabilities—
which must produce markers of success on some indicators—also grow interdepen-
dencies and scales of operation that invoke complexity penalties (Fig. 1’s mismatched
trajectories). The capability growth will produce new forms of conflict, congestion,
cascade and surprise so that operating in the strategic agility gap is unavoidable.
SNAFU catching is essential for the viability of adaptive systems in complex
worlds. But organizations rationalize this core finding away on grounds of rarity,
prevention, compliance. The first claim is: SNAFUs occur rarely given the organi-
zation’s design thus investing in SNAFU catching is a narrow issue of low prior-
ity. The second claim is: there is a record of improvement that reduces the likeli-
hood/severity/difficulty of SNAFUs. Third, when SNAFUs occur, poor response is
due to people who fail to work to the rules for their role within the organization’s
design.
These rationalizations are wrong empirically, technically, theoretically. As organi-
zations focus on making systems work faster, better, and cheaper, they develop new
plans embodied in procedures, automation, policies, and forcing functions. These
plans are seen as effective since they represent improvements relative to how the
system worked previously. When surprising results occur, the organization inter-
prets the surprises as deviations—erratic people were unable to work to plan, to
work to their role within the plan, and to work to the rules prescribed for their role.
The countermeasures become more stringent pressures to work-to-plan, work-to-role
and work-to-rule [8]. The compliance pressure undermines the adaptive capacities
needed for SNAFU catching (initiative), creates double binds that drive adaptations
to make the system work ‘underground,’ and generates role retreat that undermines
coordinated activities.
In every risky world, improvements continue, yet we also continue to experience
major failures that puzzle organizations, industries, and stakeholders. SNAFU recurs
visibly—in June 2018 IT failures stopped online financial trading (TSB in the UK
and Canadian Stock exchanges). Befuddlement arises from a background of contin-
ued improvement on some indicators, coupled with surprising sudden performance
collapses. This combination is the signature of adaptive systems in complex environ-
ments. The scale complexity that arises from changes to increase optimality comes
at the cost of increased brittleness leading to systems
which are robust to perturbations they were designed to handle, yet fragile to unexpected
perturbations and design flaws [4, p. 2529].

As scale and interdependencies increase, a system’s performance on average

increases, but there is also an increase in the proportion of large collapses/failures.
The Strategic Agility Gap: How Organizations … 101

Given the pursuit of optimality increases brittleness, why don’t more failures
occur?—SNAFU catching. Adapting to handle the regular occurrence of SNAFUs
makes the work of SNAFU catching almost invisible [15]. The fluency law states:
well adapted activity occurs with a facility that belies the difficulty of the demands resolved
and the dilemmas balanced [16].

Systems that continue to adapt to changing environments, stakeholders, demands,

contexts, and constraints are poised to adapt through enabling SNAFU catching [6].
Ironically, what drives the strategic agility gap is past success. Success from
new capabilities produces growth. Improvements drive a pattern in adaptive cycles:
effective leaders take advantage of improvements to drive systems to do more, do
it faster, and in more complicated ways. Growth, and the capabilities that power it,
creates opportunities for others to hijack new capabilities as they pursue their goals.
Success drives increasing scale complexity which leads to the emergence of new
forms of SNAFU and SNAFU catching, as systems become messy again. This is
seen the rise of high frequency trading in financial markets, in ransomware, and the
influence of internet bots in elections, and more. In episodes of technology change,
new forms of conflict, congestion and cascade arise as apparent benefits are hijacked.

4 Continuous Adaptability

If organizations today must live in the strategic agility gap, given the growth driven
by technology, how can they flourish despite complexity penalties?
Answers to this question have emerged from research on resilient performance
of human adaptive systems. For organizations to flourish in the gap they need to
build and sustain the ability to continuously adapt. Today this paradigm exists in
web engineering and operations because it was necessary to keep pace with the
accelerating consequences of change as new kinds of services arose from internet
fueled capabilities [3]. Web-based companies live or die by the ability to scale their
infrastructure to accommodate increasing demand as their services provide value.
Planning for such growth requires organizations to be fluent at change and poised
to adapt. Because these organizations recognize that they operate at some velocity,
they know they will experience anomalies that threaten those services. Because web-
based services provide growing value, the value moves from optional to standard to
critical and on to existential [5].

4.1 Lessons from Web Operations

Web engineering and operations serve as a natural laboratory for studying responses
to the strategic agility gap. Outages and near outages are common even at the best-
in-class providers. Past success fuels the pace of change. Systems work at increasing
102 D. D. Woods

scale in a constantly changing environment of opportunity and risk. Web engineering

and operations is important also because all organizations are or are becoming digital
service organizations. For example, recently multiple airlines have suffered major
economic losses when IT service outages led to the collapse of the airlines ability
to manage flights. Results from this natural laboratory help reveal fundamental con-
straints on how human adaptive systems function and how organizations can flourish
in the strategic agility gap.
Organizational systems succeed despite the basic limits of plans in a complex,
interdependent and changing environment because responsible people adapt to make
the system work despite its design—SNAFU catching. The ingredients are:
• anticipation—seeing developing signs of trouble ahead to begin to adapt before the
evidence is definitive (waiting till evidence is definitive almost guarantees being
slow and stale);
• contingent synchronization—adjusting how different roles at different levels
coordinate their activities to keep pace with tempo of events;
• readiness to respond—developing deployable and mobilizable response capabil-
ities in advance of surprises;
• proactive learning—learning about brittleness and sources of resilient perfor-
mance before major collapses or accidents occur by studying how surprises are
caught and resolved.

4.2 Four Capabilities for Continuous Adaptation

Results on resilient performance in web operations reveals specific capabilities for

effective organizations living in the gap. Initiative is essential for adaptation to con-
flicting pressures, constant risk of overload, and inevitable surprises [16]. Organi-
zations need to guide the expression of initiative to ensure synchronization across
roles tailored to changing situations. This requires pushing initiative down to units
of action [9]. Initiative can run too wide when undirected leading to fragmentation,
working at cross-purposes, and mis-synchronization across roles. However, initia-
tive is reduced or eliminated by pressure to work-to-rule/work-to-plan, especially by
threats of sanctions should adaptations prove ineffective or erroneous in hindsight.
Emphasis on work-to-rule/work-to-plan compliance limits adaptive capacity when
events occur that do not meet assumptions in the plan, impasses block progress, or
when opportunities arise.
Resilience engineering is then left with the task of specifying what system archi-
tecture balances the expression of initiative as the potential for surprise waxes and
wanes. The pressures generated by other interdependent units either energizes or
reduces initiative and therefore the capacity to adapt. These pressures also change
how initiative is synchronized across roles and levels. The pressures constrain and
direct how the expression of initiative prioritizes some goals and sacrifices other
goals when conflicts across goals intensify.
The Strategic Agility Gap: How Organizations … 103

Effective organizations living in the gap build reciprocity across roles and levels
[11]. Reciprocity in collaborative work is commitment to mutual assistance. With
reciprocity, one unit donates from their limited resources now to help another in their
role, so both achieve benefits for overarching goals, and trusts that when the roles
are reversed, the other unit will come to its aid.
Each unit operates under limited resources in terms of energy, workload, time,
attention for carrying out each role. Diverting some these resources to assist cre-
ates opportunity costs and workload management costs for the donating unit. Units
can ignore other interdependent roles and focus their resources on meeting just the
performance standards set for their role alone. Pressures for compliance undermine
the willingness to reach across roles and coordinate when anomalies and surprises
occur. This increases brittleness and undermines coordinated activity. Reciprocity
overcomes this tendency to act selfishly and narrowly. Interdependent units in a
network should show a willingness to invest energy to accommodate other units,
specifically when the other units’ performance is at risk.
Third, a key lesson from studies of resilience is that tangible experiences of sur-
prise are powerful drivers for learning how to guide adaptability. Tangible experience
with surprises helps organizations see SNAFU concretely and to see how people
adapt as difficulties and challenges grow over time. Episodes of surprise provide the
opportunity to see when and how people re-prioritize across multiple goals when
operating in the midst of uncertainties, changing tempos and pressures.
Fourth, proactive learning from well-handled surprises contributes to re-
calibration and model updating [15]. This starts with careful study of sets of incidents
that reveal SNAFU catching [2]. What is an ‘interesting’ incident changes. Organi-
zations usually reserve limited resources to study events that threatened or resulted in
significant economic loss or harm to people. But this is inherently reactive and many
factors narrow the learning possible. To be proactive in learning about resilience
shifts the focus: study how systems work well usually despite difficulties, limited
resources, trade-offs, and surprises—SNAFU catching. In addition, effective learn-
ing requires organizations to develop lightweight mechanisms to foster the spread of
learning about SNAFU catching across roles and levels.
Strategic agility gap arises as organizations’ trajectory of improvement cannot
match the emergence of new challenges, risks, and opportunities as complexity
penalties grow (Fig. 1). To flourish in the gap requires organizations to build and
sustain capabilities for SNAFU catching.

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The Languages of Safety

Hervé Laroche

Abstract Human and organizational factors (HOF) specialists have worked hard to
develop a body of methods, tools, concepts, etc., that allow them to fulfil their mission
in a professional way within their companies. Yet they are often frustrated and feel
that they do not get the attention they deserve. Several of the chapters of the present
volume can be read as invitations for HOF specialists to develop a different approach
and adopt new types of discourse in order to get more attention from managers. I
review four possible “languages” and discuss how and to what extent they would
give more power to HOF specialists. I conclude by inviting safety people to use a
variety of languages for a variety of audiences.

Keywords Attention · Manager · HOF specialists · Discourse

1 Introduction

It’s a fact: managers are not naturally excited by human and organizational factors
(HOF) issues. Yes, top managers are always ready to issue strong verbal commitments
to safety and to set zero accident objectives. However, when it comes to budgeting
HOF actions, hiring specialists, launching studies and projects, managers appear
less convinced of the safety imperatives and show limited faith in the contribution of
HOF methods and people. HOF specialists have to find a way of getting managers’
attention in times when no accidents are happening. How can they do that? In this
book, four different answers are given to this question:
• Talk hard science (Paul Schulman, Chap. 9),
• Talk numbers and money (Daniel Mauriño, Chap. 10),
• Talk law and blame (Caroline Lacroix, Chap. 8),
• Talk complexity (David Woods, Chap. 11).

H. Laroche (B)
ESCP Europe, Paris, France
e-mail: laroche@escpeurope.eu

© The Author(s) 2020 105

B. Journé et al. (eds.), Human and Organisational Factors,
SpringerBriefs in Safety Management,
https://doi.org/10.1007/978-3-030-25639-5_12
106 H. Laroche

I will now discuss each of them, not so much on the grounds of the ideas
themselves, rather on the basis of their relevance for getting attention from managers.

2 Talk Hard Science

Paul Schulman’s assessment of the social sciences contribution to safety is rather

grim. Social scientists failed to get the ear of engineers who (rightly, according to
Schulman) find their concepts underspecified and their methods dubious. In short,
they have done bad science. Fortunately, social scientists can still amend themselves
by imitating the practices of the engineering sciences, using clearly defined variables
and building rigorous metrics.
There is no doubt that this view of scientific excellence would make many social
scientists very angry. Leaving this aside, would the alignment of HOF science meth-
ods with engineering science methods make the possible contributions from HOF
more attractive in the eyes of managers? This could be the case, if managers have
training in engineering, which is not uncommon in many industries. Yet, the sociol-
ogy of the managerial elites has evolved and is still evolving in a direction that does
not favor the engineering culture. Engineers and people from the trades have lost
precedence over professional managers (MBAs), finance-oriented people, and more
or less self-made entrepreneurs. It is also unlikely that hardened HOF science could
compete with the faith in algorithmic power of the GAFA-type firms.
Adverse effects can happen. Managers certainly have little respect for the social
sciences, compared with the engineering sciences. Yet they are keen on the psycho-
logical aspects, like leadership, soft skills, meditation and mindfulness, etc. They
often become obsessed with these dubious concepts, making “serious” social sci-
entists and people inspired by the social sciences despair. Talking hard science will
not protect them from these fads. Indeed, it is more likely than they will fall for it
more easily, meaning not-so-good social science will be replaced by quite worse
pseudo-social science.

3 Talk Numbers and Money

Daniel Mauriño takes an opposite view to Schulman’s. For him, safety specialists are
already too grounded in engineering science. Rather than talking like engineers to
impress managers, he advocates, safety specialists should talk like managers. Safety
should become a business function just like any other and talk the same language
(allocation of resources, budgets, contribution to performance, etc.). In short, if HOF
experts turn themselves into managers, the other managers will listen to them.
This reminds me of the famous words pronounced during the meeting the night
before the Challenger launch in 1986 [2]. After two hours of discussion about the
impact of low temperatures on the O’rings, the head of Engineering from Morton
The Languages of Safety 107

Thiokol was urged by his boss to “put down his engineering hat and put on his
management hat”. Behind these words we find a myth: engineers are supposed to
aim at perfection and worry only about technology while managers are supposed to
seek operational performance and worry about money. Everybody is happy with this
myth. Managers gain the power of making the final decisions while engineers keep
their hands clean. In the Challenger meeting, the engineers did not contest the final
decision made by managers, though many were still convinced that it was “away
from goodness”. What Daniel Mauriño proposes is that safety people, and especially
HOF people put on a management hat and get their hands dirty. This is the only way
to gain more power and to do their job properly.
Just as Schulman’s conception of scientific rigour can be questioned, Mauriño’s
understanding of what management means is debatable. For Mauriño, management
is direction, supervision and control. Basically, this is what Henri Fayol proposed as
early as 1916 in his Administration Industrielle et Générale [1]. A problem is that
Fayol-type definitions of management are very abstract and have little use when it
comes to describing what managers really do and how organizations really work.
Organization theories provide a much more complex portrait of what constitutes an
organization and these theories suggest that establishing safety as a function does
not guarantee that it will have more influence. What happens when safety specialists
behave like managers? Maybe they get the ear of other managers, but what will
they tell them? In advocating for safety specialists to renounce their obsession with
accident prevention, Mauriño demonstrates his faith in the rationality of management.
Reasonable (that is, calculated) decisions will be made by well-informed managers.
What the Challenger case suggests is that unreasonable choices can be made by
managers AND engineers, not because they are evil but because they lose sight of
what they are really doing and of the consequences of their choices (hence the famous
concept of normalization of deviance [2]).
As Mauriño frames it, safety specialists face a strategic choice: either they change
their identity and their language to become “safety financial officers”, as Mauriño
suggests, or they remain an independent, accident-obsessed safety service, trying to
give more weight to the avoidance of accidents. But this means, in fact, giving more
weight to the fear of accidents and their consequences; in short, scaring managers.

4 Talk Law and Blame

According to Caroline Lacroix, managers should be scared already: there is a clear

trend towards an increasing intervention of judges in verifying the compliance of
some companies (judicialization) and towards the intervention of the criminal justice
system when accidents happen (criminalization).
It is unclear, though, to what extent these trends have negative consequences for
companies (direct or indirect costs) and managers (convictions, loss of position,
etc.). Being brought before a criminal court of justice is certainly a frightening
prospect for a manager. Yet big companies and top executives benefit from powerful
108 H. Laroche

legal counsel. Criminalization of safety issues could just result in an escalation of

legal disputes. Indeed, ultimately, the level of deterrence may not be significantly
increased, at least not enough to have an effect on the behaviour of firms and of
managers. In fact, although there is a shortage of systematic data, the impression
one gets from recent cases is that, whatever the costs, big companies can survive
any kind of accident unless they are already economically or politically in a very
weak condition. The criminalization of safety issues might even offer some latitude
to powerful organizations, in that criminal justice is often very slow and offers many
opportunities for delaying tactics. A financially robust organization can easily gain
time and buffer the shock of the accident. Besides, once an accident has happened,
nobody has a real interest in weakening the company. Workers want to keep their
jobs and victims want to be compensated.
Let us suppose, though, that these trends in the world of law and justice have
some deterrence potential. Should safety specialists try and take advantage of that?
Such a strategy would imply that safety specialists strengthen their abilities in legal
matters, or that they make an alliance with legal experts. Both are unlikely. Investment
in legal competencies is very costly. And legal experts, who enjoy the privilege of
direct access to top executives, have no interest in opening their jurisdiction to safety
specialists. As noted by Caroline Lacroix, safety specialists might even have much
to lose. A logical consequence of increased criminalization is the reinforcement
of a “blame culture” down the entire managerial line. Safety specialists who have
relentlessly worked at promoting a “just culture” based on the contribution of the
HOF science would be shooting themselves in the foot.
For safety specialists, talking law and blame is thus not an option, though they may
gain some influence if, as Lacroix suggests, the courts become more knowledgeable
about safety science, and more specifically about HOF science. In highly regulated
industries, where dialogue with the regulatory bodies has an anticipatory orientation
and goes deeper into the technicalities of the safety issues, there is perhaps more
hope. Sitting at the boundary of the regulatory environment is certainly a source of
influence for safety specialists. Up to what point is, however, debatable.

5 Talk Complexity and Change

All the ways of gaining influence examined previously are based on attempts to
adopt a simple, rational language. Engineering science may be highly technical, yet
fundamentally it is just analytic knowledge. The language of safety as a business
function is also based on a rational view of an organization, which can be broken
down into smaller parts (functions). Law, however esoteric it may appear to the eyes
of the lay person, is after all, as Weber told us, the instrument of reason in the social
world. Engineering science, management practices and legal knowledge have relied
on analytic knowledge to bring stability and control.
David Woods comes up with a quite different view. His core idea is that analytic
simplification is an obsolete way of gaining control of today’s sociotechnical systems.
The Languages of Safety 109

Sociotechnical systems have changed in nature, he contends. The key metaphor

is no longer the chemical plant or the nuclear power station or a transportation
system. Rather, it is the computerized, algorithmic, decentralized, connected, highly
autonomous, evolving system. With these systems, do not expect stability, expect
change and evolution. You will always be late and you will never achieve full control:
there will always be glitches, small ones and big ones (which he calls SNAFU1 s).
Catch them before they kill you. We are in a world of complexity.
As with the other contributions, I will not discuss his ideas per se, but will rather
examine their potential power for allowing safety specialists to gain influence. In
this respect, his metaphor of complexity has two very strong features. Firstly, it
is in line with the “third industrial revolution” that everyone sees unfolding in all
industries and in our daily life. Secondly, it gives us a future. The fourth and fifth
industrial revolutions are on their way. I am not making predictions: I am talking
about what is on people’s minds today. There is little doubt that managers will
love that, if only because their biggest fear is to be seen as outdated. Symbolically,
they now compete with Elon Musk, Jeff Bezos or the people from Google. Besides,
the complexity paradigm gives them an opportunity to master a discourse with a
potential for managerial autonomy and legitimacy, after decades of finance-oriented,
shareholder domination. The complexity paradigm gives power to insiders because
the key knowledge will be held and operated by them and will remain, to a large
extent, opaque to external stakeholders.
I see no reason why safety specialists could not embrace the complexity paradigm.
Complexity is compatible with HOF, on the overall. For instance, no major effort is
needed to insert into it HRO2 concepts or the views of Karl Weick. This does not
mean that HOF specialists should always bow to the discourse of the complexity
gurus, only that they should find their voice and contribute. In its present versions
the complexity paradigm might well seem to forget the HOFs, but this is only one
more reason to connect with it.

6 Final Comments

Safety and HOFs need to be “sexed up”. HOF specialists are people in the trade
that are equipped to talk to other people in the trade, not to a class of managers that
have a universal view of their jobs and careers. These managers are more likely to
embrace the complexity paradigm than traditional engineering or standard manage-
rial thinking. Complexity is however a vast territory and there is no reason why HOF
specialists could not find their place in it.
Yet, rather than being obsessed with the top management, safety specialists should
also work at building a network of influence at all levels in the organizations. Man-
agers are a target that can be reached directly or indirectly and talking numbers and

1 Situation Normal All F_ _ _ ed Up.

2 High reliability organizations.
110 H. Laroche

money is a direct way of influence. There is no doubt that safety specialists could
make progress in this respect. Talking hard science can help them get the ears of
engineers, and engineers can relay their inputs to managers. Undoubtedly, talking
law cannot hurt, although there is little opportunity for direct power, except in the
institutional work of building external networks of expertise (setting standards, etc.).
My suggestion is that safety people learn and practice several languages for dif-
ferent audiences. I do not think they have to worry too much about possible contra-
dictions. Local and provisional coherence is what matters in organizations. Global
and continuous coherence is only a question of identity. Safety people do not need
a specific language to foster their identity. They have better than that: they have a
mission.

References

1. H. Fayol, Administration Industrielle et Générale. Bull. Société de l’Industrie Minérale 10,

5–164 (1916)
2. D. Vaughan, The Challenger Launch Decision (University of Chicago Press, 1996)

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The Dual Face of HOF in High-Risk
Organizations

Corinne Bieder

Abstract High-risk organizations commonly acknowledge the importance of

human and organizational factors (HOF). However, in practice the role played by
HOF specialists and their share of voice varies dramatically from one organization to
another. Within organizations themselves, there are some recurrent tensions around
HOF and the role HOF specialists are understood to play. This delicate situation
seems to partly stem from the gap between conventional wisdom on HOF in high-
risk organizations and how HOF specialists see HOF and their role and contribution
to organizations. Exploring this dual face of HOF and trying to better understand
where it comes from may help to reduce misunderstandings and suggest ways for-
ward to build on the remaining inevitable organizational contradictions to improve
the way HOF are considered in high-risk industries.

Keywords Human factors · Organizational factors · Safety · Complexity

1 Introduction

Although the importance of human and organizational factors (HOF) for safety is
widely and commonly acknowledged in high-risk organizations, the reality is more
qualified as to how this ‘importance’ translates into practice. Drawing a general
picture that would pretend to be representative of all high-risk organizations or even
of all parts of a given organization would be oversimplifying a diverse reality. In
addition, the way HOF are taken into account varies in time, along with the context,
the people and probably many other factors that would be worth exploring. However,
in some parts of some organizations, as the issues raised by FonCSI’s industrial
partners go to show, there is a recurrent emergence of tensions around HOF and the
role HOF specialists are understood to play. These tensions seem to partly stem from
the gap between conventional wisdom on HOF in high-risk organizations and how
HOF specialists see HOF and their role and contribution to organizations. Exploring

C. Bieder (B)
ENAC, University of Toulouse, Toulouse, France
e-mail: corinne.bieder@enac.fr

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https://doi.org/10.1007/978-3-030-25639-5_13
112 C. Bieder

the gap between this dual face of HOF and trying to characterize it may be a starting
point for envisaging ways forward to improve the way HOF are considered in high-
risk industries.

2 How HOF Specialists See HOF and How They See their
Role

Human and organizational factors are understood in many different ways, includ-
ing among so-called HOF specialists depending on their earlier education, back-
ground, experience… The emphasis may vary from one HOF specialist to another
(e.g. individual or organizational mechanisms, psychological, ergonomics or more
social aspects). However, it is commonly agreed that overall, HOF are both a specific
body of scientific knowledge on a range of aspects such as human cognition, physi-
ology, organizational mechanisms and a set of scientific methodologies to apprehend
real work situations. This distinction between what is at play in real work situations
and a theoretical view of how work should be done or how organizations should
function is at the core of HOF.
This specific scientific and methodological background leads HOF specialists to
consider themselves as experts. Indeed, this knowledge is not commonly passed on
in educational or training paths other than the social sciences. In a sense, HOF spe-
cialists see their role as the experts of reality, the spokespersons for the distinction
between real practices and theoretical processes and procedures, between organiza-
tional charts and organizations considered as living ‘bodies’. In other words, they
see their role as the constant reality bell in managers and decision-makers minds.
By bringing reality to the surface, although it is reality seen through the lenses of
their conceptual, theoretical and methodological background, they see their role as
the voice of reality, the one that everyone should absolutely listen to and consider, at
all levels of the organization including the highest echelons, to acknowledge these
differences and take benefits from them to enhance safety and more generally to
improve the overall performance.
Even though HOF specialists may initially intervene to enhance safety, analyzing
how work is done in reality and how organizations actually function goes beyond the
sole safety dimension. In this respect, they see their scope as broader than just safety,
encompassing all aspects of the way the organization functions and is managed.
Thus, they see their positioning as a core part of business management to improve
not only safety but the global performance of an organization, even if in high-risk
domains, safety is a key dimension of the global performance. However, such posi-
tioning may appear to some extent in contradiction with the claim of expert knowl-
edge. Indeed, as characterized by Ardoino [1], the expert is called upon to solve a
problem with limited scope for which the expert is known to have high levels of
knowledge and competence. In contrast, the positioning of HOF specialists would
correspond to that of consultant [1] (or process facilitator as called by Schein [5]),
The Dual Face of HOF in High-Risk Organizations 113

meaning they intervene with the aim of modifying or changing representations, atti-
tudes and the like through longer interventions and joint work with the ‘client’,
including on the problem statement and request.
Ironically, although HOF specialists claim to be experts in how reality works,
how HOF specialists see themselves could be considered a description of how HOF
specialists should be seen, rather than how they are seen in reality. Indeed, decision-
makers and top managers seem to have different views on HOF and the role of HOF
specialists in high-risk organizations, at least according to what HOF specialists
perceive.

3 How Decision Makers and Top Management See HOF

and the Role of HOF Specialists

One of the reasons for the gap between how HOF specialists see their role and how
managers see it lies in their different views on HOF. If HOF specialists see the
reality of work through their social science lenses, managers, whatever their level,
see reality through their managerial body of knowledge and tools lenses. Again,
generalizing how managers see HOF is too simplistic and caricatural an approach,
but it helps to point out where some of the current difficulties, misunderstandings
and frustrations come from, and to envisage possible ways forward. Conventional
wisdom on HOF in high-risk industries assumes, among others, that there can be a
good organization (understood as organizational structure), that everything can be
described and prescribed in processes and procedures, and that if everybody complies
with these requirements, it is the best way to ensure safety [3]. Indeed, this is how
quality is ensured.
With this understanding of HOF in mind, HOF specialists are seen as experts
having established knowledge on a limited defined scope [1, 5], human and organiza-
tional aspects, able to help solving problems with the organizational structure or pro-
cesses or procedures, through quick interventions aiming at improving them or pro-
viding knowledge/data to improve them. They can act as a support to the implemen-
tation of the current management model through inputs to improve or develop oper-
ational processes and procedures, sometimes even organizational structural settings
that are obviously directly related to safety.
Another aspect of their role is to serve as an ‘alibi’ for external justification.
By having identified HOF specialists, the organization can claim it takes HOF into
account, whatever their actual role and influence.
Regarding their primary role, their scope is naturally limited to the improve-
ment or further development of how HOF are seen (i.e. good procedures, processes,
organizational structure, selection, training…) in order to enhance safety.
Their positioning is therefore a side function supporting business which is the core
function as it is meant, taught, thought in business training (i.e. mainly production
and efficiency).
114 C. Bieder

Whereas the ambition of HOF specialists could be understood as revolutionary

with regard to how organizations are run and managed, what managers expect from
HOF specialists is far more modest and limited in scope. It comes down to providing
support to improve their current safety management practices, which means action-
able recommendations to improve prescriptions, which HOF specialists are most
often reluctant to formulate. Indeed, HOF specialists consider, with their viewpoint
strongly anchored in the reality of work, that prescriptions cannot be developed
exclusively top-down. Instead, they claim that the operators themselves, the ones
who have the best field expertise and who will be using the prescriptions, should be
involved in their development.
Eventually, significant tensions exist around how the role of HOF specialists is
perceived by HOF specialists themselves and managers respectively. To take an
engineering metaphor, from the point of view of managers, HOF specialists should
focus on the refinement of the human-machine interface rather than on the definition
of the functionalities of a technical system. To take another metaphor, they should be
good at reporting minor facts of the world, like Clark Kent does, rather than trying
to save the world as Superman does. Yet, functionality and interface both influence
each other and also ultimately what a socio-technical system will do and how it will
perform… Just as Clark Kent is part of Superman and Superman is part of Clark
Kent….

4 How to Make these Tensions Constructive: Reconciling

Superman and Clark Kent?

Is there a constructive way forward to handle this significant gap between the two
faces of HOF? Would it make sense to try and turn Superman into Clark Kent or
conversely, to try and turn Clark Kent into Superman? Would the world be better if
these two faces became a single one?
Coming back to the (at least) dual face of HOF, shedding light on these questions
would definitely require further investigation and refinement in several areas. As
mentioned earlier, a first area would be to get away from a single homogeneous
category when referring to HOF as well as to HOF specialists. The way they perceive
themselves as well as the way they believe they are perceived may be significantly
diverse. Likewise, managers are not a single homogeneous lot and would deserve a
refined categorization. Their understanding of HOF and of the role of HOF specialists
may vary dramatically with a number of factors to be investigated.
Nevertheless, HOF can be characterized as a specific way to look at work and
organizations (a more realistic one would claim HOF specialists). In a sense, HOF
can be seen as a way to make progress in ignorance by bringing to the surface
and recognizing uncertainty and contradictions in real work situations, where the
dominating management models often tend to seek to eliminate uncertainty and
contradictions. If, currently, both are seen as competing with one another and trying
The Dual Face of HOF in High-Risk Organizations 115

to impose their respective view, leading to frustration, could other ways forward be
explored?
Integration of HOF into engineering models, business models, etc., is often sug-
gested (see Laroche, chapter “The Languages of Safety”, this volume). Yet, integra-
tion leads to giving up the diversity of views and approaches, and ultimately leads
to holism rather than reflecting the complexity of reality. Yet, it is precisely this
complexity of reality that HOF specialists try hard to advocate in their daily work
by highlighting the interrelations between individuals and/or organizational entities,
how they organize themselves as well as the antagonistic objectives and character-
istics at play. In this respect, integrating HOF into other dimensions, and contenting
oneself with it, would be selling HOF’s soul to the devil. As would be trying to
impose HOF views on the overall way the organization is managed, thereby killing
the requisite variety. Acknowledging contradictions, complexity, uncertainties, in a
sense the need for system thinking, is part of HOF experience, if not at the core of
it, and not trying to eliminate all of the competitive and antagonistic characteristics
between the parts is precisely at the core of system thinking [4].
More exchanges between HOF specialists and managers, developing a better
understanding of their respective worlds and views could possibly help to resolve
unnecessary contradictions (not all contradictions) and could be a middle way to
explore between the integration and missionary extremes. For a start, it would help
to adjust the type of interventions and postures of HOF specialists to the context
and conditions, between content expert, process facilitator [5] or a more political
action through generic “speech” and models with a performative aim to change
representations on the role of humans and organizations in safety [2].
Nevertheless, the inevitable remaining contradictions will perpetrate, at least to
some extent, the dual face of HOF and its ambivalent effect. HOF specialists will
continue to propose ways forward, although they know there is no definite and sustain-
able solution despite what managers believe and expect. They will thereby continue
to create disappointment and frustration at the manager level, but at the same time,
will continue to claim they were not given sufficient leeway to act and that more
interventions are needed. A tricky simultaneously vicious and virtuous circle!

References

1. J. Ardoino, Les postures (ou impostures) respectives du chercheur, de l’expert et du consultant.

Les nouvelles formes de la recherche en éducation 2, 79–87 (1990)
2. P. Bourdieu, Décrire et prescrire [Note sur les conditions de possibilité et les limites de l’efficacité
politique], in Actes de la recherche en sciences sociales, vol. 38, mai 1981. La représentation
politique-2 (1981), pp. 69–73. https://doi.org/10.3406/arss.1981.2120, https://www.persee.fr/
doc/arss_0335-5322_1981_num_38_1_2120
3. IRSN, Les Facteurs Organisationnels et Humains de la gestion des risques: idées reçues, idées
déçues. Rapport DSR n°438 (2011)
116 C. Bieder

4. E. Morin, From the concept of system to the paradigm of complexity. J. Soc. Evol. Syst. 15(4),
371–385 (1992)
5. E.H. Schein, The role of the consultant: content expert or process facilitator? J. Couns. Dev.
56(6), 339–343 (1978)

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter’s Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter’s Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Human and Organisational Factors: Fad
or not Fad?

Jean-Christophe Le Coze

Abstract In this chapter, I take a step back in order to add some elements of discus-
sion by embedding human and organisational factors within a broader historical and
sociological context that has so far not been available in the literature. The reason
for doing so is that there is a proliferation of various methods, ideas and models in
this area. By comparing this phenomenon with the development, over the past two
to three decades, of a management market in which consulting companies, business
schools and publishers constitute the main actors and institutions, it is shown that
human and organisational factors can also be described through similar patterns. I
conclude the chapter with a suggestion that one important task for industries and
regulators might be to help clarify expectations considering this diversity.

Keywords Human and organisational factors · Fads · Safety products and market ·
Consulting · Research · Regulators

1 Introduction

In the past 20 years in France and in other countries, the expression “human and
organisational factors” (HOF) has become the standard way to refer to a wide range
of contributions in the field of safety. These contributions rely on the human and social
sciences to assert the importance of properly addressing the specific characteristics
of humans and organisations in sociotechnical systems, a problem amplified in safety
critical or high-risk systems (nuclear power plants, aircrafts, chemical plants, rail-
ways, etc.) due to their hazardous potential. A wide range of disciplines are involved,
including psychology, social-psychology, ergonomics, management and sociology.
In the field of safety, this expression, HOF, very often embraces a continuum
or perhaps, what could be best described as a mixture of research and practice, of
academics and consultants, of regulators and actors of private companies all of whom
are involved in the production, promotion and conceptualisation of methods, ideas

J.-C. Le Coze (B)

INERIS, Verneuil-en-Halatte, France
e-mail: Jean-Christophe.LECOZE@ineris.fr

© The Author(s) 2020 117

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https://doi.org/10.1007/978-3-030-25639-5_14
118 J.-C. Le Coze

and models. Safety culture, crew resource management, behavioural based safety,
high-reliability organisations, swiss cheese, just culture, safety check-list, safety
leadership, golden rules, vision zero, resilience engineering or safety II…are the
most visible examples [14].
This proliferation of ideas, methods, practices and models has never really been
studied although it is an intriguing phenomenon.
Yet, the development of human and organisational factors is parallel to a similar
but even broader dynamic in the past 20–30 years which has been empirically studied
by management researchers, namely the explosion of a market for management ideas
in the 1980s, served by a thriving consulting industry [3–5, 11, 15, 16]. Researchers
of this topic are interested in different aspects of its evolution, and their work provides
highly relevant insights to thinking about human and organisational factors.

2 Studying Management as a Market

The knowledge economy, the post-industrial, information or network society are

examples of expressions designed to capture some of the macro-mutations of the past
decades in areas of work, organisations or capitalism in which the service economy
has a central place, including consulting. In this discourse, knowledge is at the heart
of the competitive advantage of companies, and managerial innovation is part of this
trend, supported by a diversity of actors.
Authors writing about management consulting adopt a variety of angles ranging
from historical, psychological, economic to sociological lenses. Topics include, for
instance, the origin and history of management consulting, the issue of fads and
fashions in management methods, the rise of management gurus, the structure of
consulting companies, the identity of consultants or the client-consultant relationship.
They illustrate and explain how management, over the last two decades, has evolved
into a highly dynamic market, where companies consume management products
available in many forms. These can be books, conferences, videos or services by
consultants. Let us comment briefly on a selected number of these topics.
The increased number, size and complexity of corporations, the presence of the
military industrial complex, the development of many administrations but also the
expansion of business schools and business press constitute the historical background
driving this explosion during the second half of the 20th Century. In a nutshell, the
advent of a new class of employees differentiated from company owners at the
beginning of the 20th Century, namely managers, combined with the increasing size
and complexity of corporations, produced a need for education in the new area of
management. Business schools were created out of this need, and research in man-
agement followed, feeding a scientific, business and management press publishing
periodicals, journals and books on the topic.
The institutional view of this phenomenon, conceptualising the interactions
between business schools, private consulting companies and business publishers and
press, pursues this historical analysis into our present situation to show how these
Human and Organisational Factors: Fad or not Fad? 119

key actors generate and fuel the dynamic of the past two to three decades in this area
[5, 15].
Part of this dynamic of the management market has been described as having
the traits of management fashions or fads [10]. Researchers have identified cycles
that resemble fashion but applied to management, namely a rise and fall of methods,
ideas, tools or practices which companies apply in sequence, or sometimes in combi-
nation, but which change as time passes. Well-known examples abound. Total quality
management, corporate culture, balanced scoreboard, business re-engineering, lead-
ership, six sigma, lean management, empowerment or digital disruption are some of
these cases of very popular themes that anyone with working experience is bound to
have heard of.
Hypothesised reasons for such cycles of fashions or fads are numerous. They
range from the quality of how well these products are marketed to be appealing
to consumers, to the insecurity of managers. They thus offer simple principles to
deal with a still-complex management problem. They bring elements of response to
the need to feel in control, and they also support the construction of a management
identity by framing expectations. In addition, they are sufficiently flexible to be
applied in various contexts which makes them quite unspecified and not restricted to
a particular area. After a while, once a product has been sold successfully, new offers
emerge which capture another way of improving management, based on alternative
principles to those of the current fashion. And the cycle continues.
Now, these fashions and fads do not operate in a simplistic way, and one criticism of
some of these studies is their absence of empirical analysis about the way managers
and employees of corporations actually use these methods and ideas. This area,
referred to as the client-consultant relationship, has various analytical facets, from
critical to more neutral ones. The critical view by academics sees in these trends a
capitalist drive for making profits and for ideologically influencing the way managers
think about how they see people, businesses and markets.
They see consultants exploiting the need of managers to be reassured, to be helped
with simplistic ideas, to impress others through cutting-edge thinking, etc. One prob-
lem is that they also tend to simplify the reality of how methods and ideas really travel
from consultant to management and employees of organisations in practice, but also
how new management ideas are produced. Let us comment on these two aspects. First,
people in organisations are not passive recipients of management recipes. They can
be highly suspicious (or even cynical) and are, at least, systematically active trans-
lators of these methods and ideas. Of course, to talk of people in organisations in
general is not good enough, because it is important to distinguish categories of peo-
ple here; between the diversity of hierarchical and functional layers of organisations,
there are as many views as there are individuals.
For instance, it is not unusual for top management to embrace new managerial
fashions when lower levels of the organisation are unimpressed by them, sometimes
reluctant to deploy the fad or even resisting its implementation, whether promoted
or not with the help of consultants. But the competition between consultants is also
fierce, all of them competing to get the attention of their potential buyers and con-
sumers of services. Consultants in their diversity are in very different positions with
120 J.-C. Le Coze

companies, and also struggle to sell their products and expertise, depending on com-
plex decision-making processes within organisations, between the presentations of
their ideas to obtaining a contract [17].
The relationship between consultants, ideas, methods and real practices is there-
fore more complex than the critical, or one-way, approach suggests. People in organ-
isations are never totally passive consumers of management products, but are active
translators instead. In relation to this, and as the second point, methods and ideas
advocated by consultants do not come out of nowhere…they are in many cases
coming from the practices of individuals in companies that innovate. These people
innovate but without necessarily conceptualising their practices then marketing and
selling them; but consultants do. So, again, the relationship between organisations,
consultants, methods and ideas is far more complex than a one-way vision.

3 Human and Organisational Factors in the Light

of Management Market Research

This summarised picture of some of the research topics and outcomes associated
with the study of the management market should be familiar to anyone involved
in safety research and practice because the patterns described and analysed above
correspond, at least partly, to what has happened in this field over the past two to three
decades. Similarly, as introduced briefly earlier, an explosion of methods, ideas and
consultants has been seen. In 1988, only a few human and organisational methods
or concepts were available in comparison to the situation thirty years later in 2018.
The concept of safety culture did not really exist at the time, or was only starting to
be mentioned explicitly. The practice of crew resource management was in its infancy.
The notion of human error was only ten years old, with major conceptualisation still
to come. High reliability organisation was not a management label and was only a
recently published idea. So, it is mainly in the past two to three decades, like with
management, that the explosion of a safety market has occurred.
It is very tempting to copy and paste the mode of institutional analysis applied in
management research, from a historical and sociological point of view. Comparable
actors and institutions are involved in the production of a safety market: consultants,
academics, safety publishers and press. There are no quantitative figures which would
help to substantiate a comparison between the two fields, management and safety.
One can imagine without taking too much risk that the safety market is only a tiny
fraction of what the management market represents but the analogy between the two
is still highly informative.
One major difference is the importance and presence of active regulators. In safety,
and more so in high-risk systems, regulators can be the promoters of certain methods
and ideas, and cases of prescribed notions such as just culture, safety culture or
resilience are now available. In concrete terms, this means that such concepts have
become expected and required in various contexts through regulations. Therefore,
Human and Organisational Factors: Fad or not Fad? 121

Fig. 1 Core actors and institutions of the safety market

one needs to slightly expand the key actors and institutions behind the safety market
in comparison with the management market, to include the regulators (Fig. 1).
One message of this chapter is that to understand human and organisational fac-
tors, one also therefore needs to understand the complex paths followed by concepts
as products of the interactions between these different actors and institutions, fol-
lowing and extending Laroche’s commodification approach of safety culture [12].
The methods and ideas of human and organisational factors have different historical
and sociological trajectories. Let us illustrate these briefly with one example, safety
culture [14].
The story of safety culture (SC) can be found in many articles and books [2]. Its
origin is linked to Chernobyl and some official reports referring to this idea. From
there, the concept was picked up in several directions, some more academically
oriented, some more practically oriented. From the academic point of view, it is a
controversial notion [1], with opposing views about its value, from scholars who
produce practical versions to be implemented by multinationals (e.g. [8]) to those
who reject it (e.g. [7]). Safety culture is a fairly well-established product sold by
consultants when associated with the maturity principle which sets out that there are
several stages of achievement [6]. And safety culture has also been introduced into
regulations, such as in the Norwegian petroleum industry (for a recent discussion,
see Antonsen et al. [2].
Other cases of methods, ideas, models and concepts exist (e.g. crew resource
management, behavioural based safety, high reliability organisations, vision zero, just
culture, resilience, etc., see [13]. They would reveal the complexity of the interactions
between the different actors generating them, and the patterns associated.
122 J.-C. Le Coze

4 Discussion and Conclusion

This proliferation of available methods, ideas, models and consultants gives rise to
many questions if one pursues the comparison with the management market studies,
and if one considers that companies internalise as much as externalise their human
and organisational factors expertise (see the case of UK railway in Ryan, this book,
chapter “Accounting for Differing Perspectives and Values: The Rail Industry”). One
is about fashions and fads. Can we consider the abundance of products in human
and organisational factors to be fashions or fads? Are human and organisational
factors different? If yes, why and how? A follow-up question could be How do
organisations deal with this diversity of products, whether fads or not fads? How
do companies articulate this diversity? Do they? Does it differ between high-risk
industries considering their diverse contexts? Another one is about practices. How
are these safety products concretely translated in organisational practices? How do
they efficiently contribute to create, improve or maintain safety?
More work is needed if one considers these to be important questions. They are
clearly quite complex ones requiring empirical investigations, but it seems obvious
that facing this diversity of possibilities, companies are, for the moment, left to
think for themselves about the best options to follow, and some chapters of this
book illustrate this with concrete examples. Maturity in this respect depends on the
resources and context of high-risk systems, aviation probably being at the high-
end (Reuzeau, this book, chapter “The Key Drivers to Setting up a Valuable and
Sustainable HOF Approach in a High-Risk Company such as Airbus”) while other
industries at a lower end of the continuum.
If regulators are important actors and institutions promoting the introduction of
human and organisational factors (Mearns, this book, chapter “Safety Leadership
and Human and Organisational Factors (HOF)—Where Do We Go from Here?”),
then one role they could play, with the support of academics, consultants and industry
experts, is to offer guidance about what is expected from high-risk systems in terms
of the different possibilities available offered to improve practices with the help of
this diversity of methods, ideas and models. This would not imply going as far as
prescribing the use of particular methods but providing clarity instead among their
diversity (e.g. [9]).

References

1. S. Antonsen, Safety culture assessment: a mission impossible? J. Contingencies Crisis Manag.

17(4), 242–254 (2009)
2. S. Antonsen, M. Nilsen, P. Almklov, Regulating the intangible. Searching for safety culture in
the Norwegian petroleum industry. Saf. Sci. 92, 232–240 (2017)
3. T. Clark, R. Fincham, Critical Consulting: New Perspectives on the Management Advice
Industry (Blackwell, Oxford, 2002)
4. T. Clark, M. Kipping, The Oxford Handbook of Management Consulting (Oxford University
Press, Oxford, 2012)
Human and Organisational Factors: Fad or not Fad? 123

5. L. Engwall, M. Kipping, B. Üsdiken, Defining Management. Business Schools, Consultants,

Media (Routledge, New York, 2016)
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Sci. 105, 192–211 (2018)
7. A. Hopkins, Quiet outrage. The way of a sociologist (2016). Wolters Kluwer CCH
8. P. Hudson, Implementing a safety culture in a major multi-national. Saf. Sci. 45, 697–722
(2007)
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10. N. Jung, A. Kieser, Consultants in the management fashion arena, in The Oxford Handbook
of Management Consulting, ed. by T. Clark, M. Kipping (Oxford University Press, Oxford,
2012), pp. 327–346
11. M. Kipping, L. Engwall, Management consulting. Emergence and dynamics of a knowledge
industry (Oxford University Press, Oxford, 2002)
12. H. Laroche, The commodification of safety culture and how to escape it, in Safety Cultures,
Safety Models: Taking Stock and Moving Forward, ed. by C. Gilbert, B. Journé, H. Laroche,
C. Bieder (Springer, Cham, 2018), pp. 151–158
13. J.C. Le Coze, Vive la diversité. HRO and resilience engineering. Safety Science (2016). https://
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15. K. Sahlin-Andersson, L. Engwall, The Expansion of Management Knowledge. Carriers, Flows,
and Sources (Stanford Business Books, Stanford, 2002)
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(1997)
17. A.J. Sturdy, K. Handley, T. Clark, R. Fincham, Management Consultancy, Boundaries and
Knowledge in Action (Oxford University Press, Oxford, 2009)

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter’s Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter’s Creative Commons license and your intended use is not permitted by
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Breaking the Glass Ceiling: Levers
to Promote the Influence of Human
and Organizational Factors in High-Risk
Industries

Benoit Journé

Abstract A growing gap is emerging between the increase in human and organiza-
tional factors (HOF) expertise and the success of HOF operational approaches, and
the rather weak influence of HOF at the strategic level of organizations. This chapter
seeks to understand this paradox and identify some levers to promote HOF influence.
We assume that (1) the paradox is an outcome of the “long road” of evolutions in
HOF knowledge and its experts over forty years; (2) these evolutions have multiplied
concepts and practices without a clear global coherence and without a political and
institutional agenda; (3) breaking the HOF “glass ceiling” requires action on several
levers at the conceptual level, the professional level, the management level and finally
at political and institutional levels.

Keywords HOF evolution · Glass ceiling · Paradox

1 Introduction

It is now widely accepted that industrial safety is not just a question of technical design
and engineering. Academics have produced a significant amount of knowledge about
human and organizational factors (HOF). A set of HOF principles has been defined,
and many concrete actions and programs have been successfully implemented at an
operational level by emerging communities of HOF experts and practitioners.
But behind this apparent success, HOF are currently facing a challenging paradox.
Indeed, even in the most advanced companies, the dramatic development of HOF
knowledge and practices has not really helped to increase the influence of HOF on the
strategic and management decisions that could have a significant impact on safety.
In other words, a “glass ceiling” has emerged.
This lack of influence at the strategic and executive levels may have a negative
feedback on HOF practices implemented at the operational level. This occurs every
time a management tool is implemented, or a strategic decision is made that ignores

B. Journé (B)
Université de Nantes, Nantes, France
e-mail: Benoit.Journe@univ-nantes.fr

© The Author(s) 2020 125

B. Journé et al. (eds.), Human and Organisational Factors,
SpringerBriefs in Safety Management,
https://doi.org/10.1007/978-3-030-25639-5_15
126 B. Journé

or even contradicts HOF principles, meaning that HOF risk losing influence at all
levels.
The key idea of this chapter is the following: breaking the glass ceiling cannot be
limited to the presence of HOF experts within the board of directors. HOF influence
lies in its legitimacy rooted in its expertise. HOF experts are not meant to directly
participate in strategic decision-making, but could be involved in the rebuilding of a
conceptual and practical coherence as well as in institutional work that could put HOF
knowledge and practices at the core of strategic decision processes, management
practices, management tools and operational practices.

2 The Evolution of HOF: Extending the Scope

of Knowledge and the Variety of Issues

The evolution of HOF doctrines and practices shows a continuous enlargement of

their scope. This has been fueled by both the analysis of normal functioning and the
lessons learned from major accidents in high risk industries.

2.1 From Human-Machine Interactions and Human Error…

HOF practices are rooted in ergonomic models of people at work (physical and
cognitive) in order to optimize human-machine interactions. “Human factors” and
ergonomics emphasize the importance of “human errors” and the need to reduce
them, at the individual level (optimization of human-machine interactions, fighting
against “error inducing” designs) as well as at the collective level (“Crew Resource
Management”). Such approaches still exist through “human performance” programs
and best practices, but remain limited by important drawbacks caused by their
“behavioral” and psychological biases.

2.2 …To Organizational Factors…

However, the concept of “human error” is not purely behavioral, cognitive or techni-
cal, it also opens the way to organizational and managerial approaches. Errors are not
limited to imperfections and weaknesses that should be eradicated through intensive
training, good procedures and tight management and control or moral values. Their
human dimension lies in them being an integral part of the normal functioning of
humans in the real world. The challenge for safety is not to suppress all forms of
errors, but to use human errors to access the complexity of the risky socio-technical
Breaking the Glass Ceiling: Levers to Promote the Influence … 127

system that is operated [7]. Managing human errors requires both transparency (to
understand what really happened) and learning processes (to prevent repetition of
the same error).
The managerial implications of this assumption are crucial. Errors must be distin-
guished from faults or intentional violations. This evolution is based on the promotion
of “just culture” as a key component of a wider “safety culture”, and on the abandon
of “blame culture”.
Hence, blaming errors becomes a management fault that impedes transparency
(increasing organizational silence) and learning processes and therefore produce
negative impacts on safety.
This represents a turning-point. HOF are no longer referring only to “human
factors” and instead are examining “organizational factors”: safety can be negatively
or positively affected by organizations and not just by people or technology. The
process of “normalization of deviance” [12] demonstrated that, for example, rather
than there being someone who broke the existing NASA procedures, the whole
Challenger launch procedure and management practices related to decision-making
deviated from safety to performance goals and “produced” the accident.
Conversely, the High Reliability Organizations theory (HRO) showed that safety
is “produced” during normal functioning by specific organizational settings and pro-
cesses, and by management practices and culture [8]. Safety appears to be the out-
come of a “social order” [11]. The emphasis is put on the way organizations deal
with competing objectives and competing professional groups.

2.3 …To Inter-organizational and Institutional Relationships

HOF have recently tackled a wider issue: the impact of inter-organizational relation-
ships on safety. This includes relationships between licensees and subcontractors as
well as between the regulator (or auditor) and licensees (or auditees) and supposes
to develop a new institutional approach to safety. A lot is still to be done in this new
area.

3 The Glass Ceiling Paradox of HOF: Growing Knowledge,

but Weak Influence

The extension of the scope and the issues tackled by HOF represents significant
progress, but also reveals a major weakness since it did not provide HOF with more
influence in the decisions made by organizations. Despite the emergence of HOF
networks and professional communities that implemented HOF programs at a very
operational level, many HOF practitioners are aware of the weak influence HOF have
on top management decisions. Our assumption is that this growing gap between
128 B. Journé

knowledge and influence reveals the existence of a “glass ceiling” favorizing the
rise of an organizational hypocrisy [2]. The HOF discourse about safety is totally
neglected or contradicted by the board of directors and strategic decision makers
when it comes to safety issues. This is a major threat because HOF may lose their
legitimacy from the point of view of fieldworkers and first line managers who take a
crucial part in the production of safety performances. Furthermore, the multiplication
of issues tackled by HOF, may create confusion in the messages delivered to the
practitioners.

4 Levers for an Influential HOF in Organizations

Several levers can be activated to break the glass ceiling and strengthen the influence
and the coherence of HOF approaches all over the organization. We distinguish
between academic and empirical levers, but these interact and should obviously be
activated together, and the academic ones should feed several of the empirical ones.

4.1 Academic and Conceptual Levers for Multiple

but Coherent HOF Research and Knowledge Integration

Academically, the first challenge is to link together human factors and organizational
factors into a more integrated HOF approach. As suggested before, the evolution of
HOF from human factors (micro level) to organizational factors (meso level) to inter-
organizational factors (macro level) has required a multiplication of concepts, meth-
ods and models borrowed from various academic disciplines beyond ergonomics:
psychology, sociology, anthropology, management, safety sciences, political sci-
ences… Although these disciplines compete or sometimes collaborate with diffi-
culty, it is very important to preserve this plurality of approaches to prevent the risk
of over-simplification of safety and security issues.
How then to reintroduce coherence while keeping the plurality of the
approaches? A limited, but strong and coherent core set of concepts bridging the
micro/meso/macro levels and the various disciplines involved must be defined. We
believe the concepts of “activity” and “organizing” can play this role, for a number
of reasons. First, they are cross-disciplinary. Second, they can operate at human,
organizational and inter-organizational levels. Third, they assume that safety is pro-
duced (or fails to be produced) by human “activities” and organizational processes.
Focusing on “organizing” is a way to assume that organizations are continuously
“happening” [10] through day-to-day activities made of decision-making, sense-
making and collective discussions about the issues and difficulties practitioners and
managers face to “do a good job”. Fourth, they put complex tensions, contradictions
and paradoxes at the core of safety issues (variety of goals and constraints; planning
Breaking the Glass Ceiling: Levers to Promote the Influence … 129

vs. managing the unexpected; etc.). Fifth, they share a common methodology based
on direct observations of very contextualized activities that take place at various
organizational and inter-organizational levels. Such observations should feed rich
case studies that could be part of a science-based and facts-based approach to HOF.
Finally, building the theoretical coherence of HOF through “activity” and “orga-
nizing” is a way to create the framework for fruitful discussions between competing
approaches (cf. normal functioning approach proposed by HRO vs. knowledge of
accidents) and various academic disciplines. Thus, we advocate1 for a pragmatist
(Dewey) and interactionist (Goffman) approach to HOF.

4.2 Empirical Levers for Embedding HOF in Actual

Organization Practices at All Levels

Some suggest that the best way to promote HOF would be to act directly at the
political level, turning HOF into a business function in high-risk industries (cf. chapter
“Turning the Management of Safety Risk into a Business Function: The Challenge
for Industrial Sociotechnical Systems in the 21st Century” by Daniel Mauriño in
this book) and/or to give a seat on the board of directors to the HOF chief executive.
Would it automatically break the glass ceiling and give HOF more influence? Possible
drawbacks exist. First, HOF experts may spend more time dealing with power issues
rather than safety issues, fighting against the interests of other business functions
and bargaining for more resources at the expenses of other functions. Second, the
presence of a HOF representative on the board of directors can be useless if their voice
is not heard, in case of self-censorship or if they get “captured” by others (abandoning
HOF’s interests and adopting others’ interests). What is true for the board of directors
can also appear to be true at every board or meeting, whatever their hierarchical level
in the company. Therefore, it is important to legitimate the actual influence of HOF
rather than their formal presence. In other words, HOF influence depends more on
being active in “organizing” processes than being present in formal “organization”.
We assume that HOF influence at the highest levels is a combination of legitimacy,
management principles, concrete management tools and organizational settings that
support the diffusion of HOF expertise across business functions and hierarchical lev-
els, inside the organization but also outside, in relation with key stakeholders. HOF
legitimacy comes from their expertise, derived from academic research, but also
from the existence of more or less formal professional communities of HOF experts
and practitioners and their reflexivity [5]. Such communities elaborate strong pro-
fessional cultures that include safety as part of “doing a good job”. But HOF experts,
professional communities and safety cultures need management support to spread
their influence from the bottom to the top of the organization. This is where man-
agement principles, management tools and organizational settings come into play.

1 InFoncsi but also in Chaire RESOH, a research project dedicated to HOF in inter-organizational
safety issues (IMT-Atlantique, Andra, IRSN, Naval group, Orano).
130 B. Journé

The coherence of HOF management tools (i.e. formal safety culture of the com-
pany, performance indicators, pre-job briefing…) and their connections with man-
agement tools used by other functions is a key issue and requires specific engineering
to prevent cacophony and promote polyphony [4]. This is especially the case with
Human Resources (competency, career, salary, social relations…), management con-
trol (industrial and financial performance reporting tools) and with higher hierarchi-
cal levels. HOF expertise may irrigate the organization through these interconnected
management tools that embed various visions of “doing a good job”. Management
processes are in place to enable discussions on professional activities and difficul-
ties with safety issues to be organized. Designing and managing discussion spaces
[3, 9] is a management responsibility. Then subsidiary management becomes the
key principle to organize the connection of hierarchical levels through the different
discussion spaces. It is also a way to make strategic managers and CEO feel really
responsible for safety and to include it in strategic discussions.
Since the top management levels and strategy oversee the relationships with the
organization’s environment, breaking the glass ceiling by addressing the top man-
agement levels with HOF expertise and safety issues, supposes to put them at the
core of the dialog with external stakeholders. It is especially the case for the regulator
and for the “civil society” that have important expectations about safety, security and
transparency. At a strategic level, safety is produced through such dialogs that have
to be engineered.
Finally, the activation of the empirical levers we have identified requires “institu-
tional work” [1, 6] realized by HOF experts and managers at various levels as a way
of building HOF legitimacy and putting HOF expertise with the right shape, at the
right time, in the right place to make the right decisions.

References

1. A. Berger-Sabbatel, B. Journé, Organizing risk communication for effective preparedness:

using plans as a catalyst for risk communication, in Risk Communication for the Future, ed.
by M. Bourrier, C. Bieder (Springer, Cham, 2018), pp. 31–44
2. N. Brunsson, The Organization of Hypocrisy: Talk, Decisions and Actions in Organizations
(Wiley, 1989)
3. M. Detchessahar, B. Journé, Managing strategic discussions in organizations: a Habermasian
perspective. M@n@gement 21(2), 773–802 (2018)
4. M. Detchessahar, S. Gentil, A. Grevin, B. Journé, Entre cacophonie et silence organisationnel,
concevoir le dialogue sur le travail. Le cas de projets de maintenance dans une industrie à
risque. Annales des Mines-Gérer et comprendre (130), 33–45 (2017)
5. J. Lave, E. Wenger, Situated Learning. Legitimate Peripheral Participation (Cambridge
University Press, Cambridge, 1991)
6. T. Lawrence, R. Suddaby, B. Leca, Institutional Work: Actors and Agency in Institutional
Studies of Organizations (Cambridge University Press, 2009)
7. J. Reason, The identification of latent organizational failures in complex systems, in Verification
and Validation of Complex Systems: Human Factors Issues, ed. by J.A. Wise, V.D. Hopkin, P.
Stager (Springer, Berlin, Heidelberg, Germany, 1993), pp. 223–237
Breaking the Glass Ceiling: Levers to Promote the Influence … 131

8. K.H. Roberts, Some characteristics of one type of high reliability organization. Organ. Sci.
1(2), 160–176 (1990)
9. R. Rocha, V. Mollo, F. Daniellou, Work debate spaces: a tool for developing a participatory
safety management. Appl. Ergon. 46, 107–114 (2015)
10. T.R. Schatzki, On organizations as they happen. Organ. Stud. 27(12), 1863–1873 (2006)
11. P.R. Schulman, The negotiated order of organizational reliability. Adm. Soc. 25(3), 353–372
(1993)
12. D. Vaughan, The Challenger Launch Decision: Risky Technology, Culture and Deviance at
NASA (University of Chicago Press, Chicago, USA, 1996)

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons license and
indicate if changes were made.
The images or other third party material in this chapter are included in the chapter’s Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter’s Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
HOF: Adjusting the Rule-Based
Safety/Managed Safety Balance
and Keeping Pace with a Changing
Reality

Caroline Kamaté

Abstract It is commonly acknowledged among at-risk industrial sectors that

improvement in safety performance requires better consideration of HOF. Tensions
and even contradictions exist between work and organisation as theoretically under-
stood, and the reality of the shop floor, with its constraints, its power games and
more. HOF specialists are, in some ways, the voice of reality in complex sociotech-
nical systems such as at-risk organisations. The HOF approach provides, at all levels,
‘adjustment loops’ to promote safe and efficient human activity and contribute to the
business whole performance. However, the way HOF are structured varies widely
depending on organisations and the expectations in terms of both impact and sus-
tainability are not always met. This final chapter briefly summarizes and discusses
some of the axes for improvement previously presented in the book.

Keywords Reality · ‘Organising’ · HOF dynamic loop

1 Introduction

It is nowadays generally accepted that if the safety strategy of a company is to be

improved, a further step must be taken in the consideration of human and organisa-
tional factors (HOF). Thus, requests on the topic of HOF abound. However, the way
HOF structures are organised denotes a heterogenous and fragmented HOF land-
scape, according to the company and even within companies. Furthermore, what is
implemented does not always meet the expectations in terms of impact and continu-
ity, hence the safety outcomes, and HOF actors sometimes deplore a lack of leeway
and integration of their contribution at the organisation’s highest levels.
Thus, although (almost) everybody is convinced about the importance of consid-
ering human and organisational factors for safety, in most industries there is a feeling
of dissatisfaction or even frustration. What are the conceptual, structural and func-

C. Kamaté (B)
FonCSI, Toulouse, France
e-mail: caroline.kamate@foncsi.org

© The Author(s) 2020 133

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SpringerBriefs in Safety Management,
https://doi.org/10.1007/978-3-030-25639-5_16
134 C. Kamaté

tional levers for an implementation of HOF approaches that efficiently contribute

to safety performance? Based on the work presented in the previous chapters of the
book, this synthesis is an attempt to summarize and build on the main findings.

2 HOF Approaches for Capturing Reality

Adopting a HOF approach means examining human work within the organisa-
tion, notably beyond the framework, rules and procedures that govern it. Indeed,
beyond the prescriptions, depending on the context and its unforeseen circumstances,
employees adapt their activity, which is not limited to the prescribed work, to ‘do their
job’. In the same way, the organisation is above all a structure, with an organisation
chart and rules which frame its functioning as well as accounts that must be rendered
to the external stakeholders. But an organisation is also a process, it is continuously
under construction: it is the living and dynamic product of a set of interactions and
social regulations. It is the outcome of an actual ‘organising’ work carried out daily
by all actors, including managers through the arbitrations they are led to do. This
organising is both vertical (between hierarchical levels) and horizontal (management
of internal and external interfaces).
This hiatus between a theoretical and normative view of how work should be
done or how organisations should function, and what really goes on in situation, is
at the core of HOF. HOF specialists have the duty to always consider reality and its
constraints, and to ‘ring the reality bell’ at all levels of the organisation. They may
somehow be considered as ‘providers of reality’.

3 Support ‘Organising’

There are some essential conditions for allowing HOF people to fulfill their functional
mission. They must be connected to the shop floor and be able to feed back reality
of work to the highest levels of the organisation. This means their words must not be
censured, and managers should also be open to listen to bad news. The freedom of
speech of HOF people is a number one priority and must be protected. HOF resources
must be deployed wherever needed in the organisation to identify contradictory issues
and support managers in their arbitrations and trade-offs to get the job done, and to
promote interactions at all levels. Thus, they favorize constant ‘organising’.
HOF: Adjusting the Rule-Based Safety/Managed Safety Balance … 135

4 Work on the Gap between Expectations and Responses

The way HOF specialists and senior managers respectively think about HOF, leads
to differences in their perception of the role of HOF specialists. There is often a
gap between some normative expectations of industry consisting in operational rec-
ommendations, quick and limited in scope interventions, and responses from HOF
actors, both academics and practitioners, that are not that ‘simple’ … As an exam-
ple, if some human factors at the workplace level can quite easily be monitored by
indicators, this is generally not the case anymore when the perimeter is extended to
the level of the organisation, even more so with a changing dimension.
HOF specialists claim that an organisation is a socio-technical system with some
human and organisational dimensions that mainly escape monitoring by indicators.
Moreover, industrial companies, like other complex systems, are basically unstable.
But despite the discourses about the impact of human and organisational factors
and their hardly quantifiable features, for most company leaders, the organisation
is seen above all as a techno-economic system, and it is mainly as such that they
‘work it out’. They perceive the role of HOF specialists as being precisely to provide
sociotechnical engineering, and not to remind them how difficult it is to do so. HOF
are expected to restore a regulated safety ensuring ‘normal stable’ operations. Most
regulators support this vision too, because it is easier to control and display, and
reassuring for public opinion.
On this basis, there is de facto unrest among HOF specialists, and frustration from
both sides. Since they cannot really fulfil the promise of socio-technical engineer-
ing, they eventually could be seen in a position of a ‘permanently failing function’.
However, they offer an ‘imperfect remedy’ for an ‘imperfect reality’, and they must
constantly get back to work because this is a never-ending mission.

5 Rebalance the O within the F

Although internal HOF structures regularly identify organisational causes when

analysing unwanted events, they usually have much more influence on human factors
than on organisational ones. There are several reasons that can explain this situation.
One is the profile of HOF specialists—mostly ergonomists and psychologists—and
their scope of intervention which is sometimes limited to health, safety and work-
ing conditions. Within that field, their expertise is fully recognized and the methods
and tools they provide are operational and have proved efficient. However, work on
organisational factors seems to remain within the purview of a different category of
actors, mainly management specialists, who, unlike most HOF specialists who work
in close interaction with front-line managers, operate at the decision-making level.
To some extent, HOF specialists face a ‘glass ceiling’ that prevent them accessing
the strategic levels of the company. This might undermine the efficiency of their
approach due to their scope of action being limited to one part of the problem, and
136 C. Kamaté

could significantly weaken their influence on strategic decisions. Unlocking this situ-
ation requires working at both conceptual and practical levels, starting with building a
more integrated and consistent approach towards HOF around the cross-disciplinary
concept of ‘organising’. Promoting training of both executive committee members
on the basis of HOF and HOF people in risk management, plus the presence of HOF
experts within the executive board to provide support for decision-makers by form-
ing binomen for example, are promising levers for safety and performance because
they promote the reconciliation of these two worlds.

6 Safety Alone Is not the Key

Companies do not have only safety to manage and the priority given to safety does
not always translate into reality. And, although this is a slight exaggeration, HOF
can be described as knowledge-oriented while managers are solution-oriented. Con-
sequently, at first glance HOF is not an issue for managers and must therefore be
turned into a managerial issue (design, productivity…). Thus, to better mobilize
around HOF, it is of strategic importance to demonstrate the connection of HOF to
other key dimensions of business performance and to overall risk management rather
than to safety only. The purpose of implementing HOF approaches is to promote safe
and efficient human activity. But beyond safety and human efficiency, better consid-
eration of HOF fosters the whole industrial performance through the integrative
function of human activity. It also leads to the limitation of costs like human cost for
performance (incidents or accidents, exhaustion, demobilization), costs due to late
identification and catch up of design errors… Rather than the safety one, hanging
this banner might give HOF people better chance to get attention from top managers.
Once ‘inoculated’, once convinced sometimes by leading examples, the will of a
few top-managers might facilitate openness to HOF from the whole organisation
and support from the direction. The HOF policy must then translate into strategic
piloting tools and the deployment of HOF resources all along the organisation’s key
processes.

7 Reinforce the Dialogue around HOF with External

Stakeholders

Depending on the industrial sector, consideration of HOF by the regulators varies

widely, with the authorities supervising civil aviation probably the more advanced in
that field. There is no doubt that the greater incorporation of HOF into the regulatory
framework is a powerful lever for improving their consideration by companies, and
therefore promoting efficient and sustainable HOF approaches. Nevertheless, the risk
exists of becoming too prescriptive and of shifting too much towards the rule-based
HOF: Adjusting the Rule-Based Safety/Managed Safety Balance … 137

safety side, thus denaturing the very purpose of HOF which is to look beyond the
rules. The emphasis should be placed on the need for industrial organisations and
regulators to share HOF fundamentals and engage a discussion.
Better knowledge and acknowledgment of HOF by judges is also a paramount
issue in view of the increasing judicialization of industrial disasters. This is reflected
by the good reception given by the European Parliament to the concept of just culture
in civil aviation.
More globally, better consideration of HOF in inter-organisational relationships
requires an institutional work which represents a promising area for renewed safety
approaches.

8 Assume the Dual Objective of HOF Structuring

The way HOF are structured in a company must serve objectives of two different
natures. HOF must be well structured to achieve their primary functional purpose
as reality sensors which largely consists in managing the gaps between the work as
it is conceived and the work as it is done, and seeking to narrow the gap. For that
purpose, HOF must be networked and finely inserted in processes where safety is
‘manufactured’. Nevertheless, HOF structure also has a symbolic scope. Internally, it
positions HOF within the organisation’s culture, establishing the permanence of the
HOF approach, its relevance and legitimacy. Regarding the external environment of
the company, it stresses the importance given to safety, designates the stakeholders’
interlocutors and publicizes compliance with explicit or implicit standards. This
symbolic role requires a much more visible and homogenous structuration. The
risk exists that company leaders, in their arbitrations, emphasise the symbolic role
because it is more visible and appears the most ‘profitable’ in the short term. But they
need to adopt both strategies and assume this duality. The idea is to use the symbolic
structure as an entry and exit point, providing a framework to the functional role of
HOF, the stake being that HOF people can operate, benefiting from the resources
and leeway they need.

9 The HOF Virtuous Loop

The importance of overcoming old models essentially based on rule-based safety

is nowadays more widely acknowledged. Since hazardous industries, like any other
complex systems, are dynamic and unstable socio-technical systems, the largest
potential for progression lies on the side of managed safety, which could also be
named initiative-based safety. By starting from the real work with emphasis on
‘organising’, HOF approaches promote, at all levels, ‘loops of adjustment’ between
the top managerial models and the reality of work. By identifying paradoxes and
supporting the consideration of the different points of view, the HOF loop seeks
138 C. Kamaté

to turn tensions into opportunities for improvement, rather than becoming sources
of blockage. The instability of industrial organisations must be accepted in order to
anticipate and adapt to future changes. Uncertainty, risk and a certain incompleteness
contribute to adaptation, while trying to find fixed solutions carries the risk for organ-
isations of always fall behind the times in a constantly changing world. Thus, rather
than aiming to achieve perfection at a given moment, the HOF loop participates in
considering imperfection as an asset rather than a problem, therefore contributing to
organisational agility.
To keep the HOF loop dynamic and successful, HOF specialists face great chal-
lenges. They must provide advice and support at the highest level of the organisation,
while keeping in touch with the reality of the shop floor. Being close both to decision-
makers and to the workplace, maintaining the same interest for the work of all those
who contribute to safety and the same quality of dialogue requires them to master
different languages. They have to make decisions about the right battles to be fought,
which managers should be supported in their arbitrations and which resources must
be negotiated. Their voice is essential and must weigh in the conduct of technical and
organisational changes. And, of course, they must continuously stay up-to-date with
advances in cognitive, social and organisational sciences. All of this requires the top
management to be open to HOF and to unconditionally support implementation of a
consistent HOF approach.

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