Ergonomic Insights

This book provides a great collection of work design testimonies with transferable
lessons across many industry sectors and domains. It discusses physiological and
cognitive parameters, teamwork, social aspects, and organisational and broader fac-
tors that influence work design initiatives.
It is important to learn from practitioner stories and ­real-world conditions that
affect the theoretical applications of work design. Readers will benefit from under-
standing the struggles and successes of the authors. The chapters cover a wide spec-
trum of human factors and user needs, including ­decision-making in (­ab)­normal and
­safety-critical situations, physical ergonomics, d­ esign-­in-use modifications, and tai-
lored training. The text examines holistic approaches that lead to improved work
methods, worker engagement, and effective ­system-wide interventions.
Ergonomic Insights: Successes and Failures of Work Design is primarily written
for professionals and graduate students in the fields of ergonomics, human factors,
and occupational health and safety. Educators will also benefit from using these case
studies in class lessons.
 Workplace Insights: ­Real-World
Health, Safety, ­Well-being, and Human
Performance Cases
Series Editors:
Nektarios Karanikas and Sara Pazell

The aim of the series is to host and disseminate ­real-world case studies at workplaces
with a focus on balancing technical information with honest insights and reflections.
Further, the application of a work design framework will propel this series into the
literary crossover of traditional occupational health, safety, ­well-being, human fac-
tors engineering, or organisational sciences, into a design realm like no other series
has done. Each book in this series will include cases sharing the tools and approaches
applied per the work (­re)­design stages (Discovery, Design, Realisation). They will
inform the readers with a complete picture and comprehensive understanding of the
what’s and why’s of successful and “­failed” attempts to improve the work health,
safety, ­well-being, and performance within organisations.

Safety Insights
Success and Failure Stories of Practitioners
Edited by Nektarios Karanikas and Maria Mikela Chatzimichailidou
Ergonomic Insights
Successes and Failures of Work Design
Edited by Nektarios Karanikas and Sara Pazell

For more information on this series, please visit: https://­

www.routledge.com/
­­Workplace-Insights/ ­­book-series/­CRCWIRWHSWHPC
 Ergonomic Insights
Successes and Failures of Work Design

Edited by
Nektarios Karanikas and Sara Pazell
First edition published 2023
by CRC Press
6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL ­33487-2742

and by CRC Press

4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN

CRC Press is an imprint of Taylor & Francis Group, LLC

© 2023 selection and editorial matter, Nektarios Karanikas and Sara Pazell; individual chapters, the
contributors

Reasonable efforts have been made to publish reliable data and information, but the author and
­publisher cannot assume responsibility for the validity of all materials or the consequences of
their use. The authors and publishers have attempted to trace the copyright holders of all material
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Library of Congress Cataloging-in-Publication Data

Names: Karanikas, Nektarios, editor. | Pazell, Sara, editor.
Title: Ergonomic insights : successes and failures of work design / edited
by Nektarios Karanikas and Sara Pazell.
Description: First edition. | Boca Raton, FL : CRC Press, 2023. | Series:
Workplace insights: real-world health, safety, wellbeing and human
performance cases | Includes bibliographical references and index.
Identifiers: LCCN 2022032310 (print) | LCCN 2022032311 (ebook) |
ISBN 9781032210322 (pbk) | ISBN 9781032394930 (hbk) |
ISBN 9781003349976 (ebk)
Subjects: LCSH: Work design. | Human engineering.
Classification: LCC T60.8 .E74 2023 (print) | LCC T60.8 (ebook) |
DDC 620.8/2–dc23/eng/20221006
LC record available at https://lccn.loc.gov/2022032310
LC ebook record available at https://lccn.loc.gov/2022032311

ISBN: ­978-­1-­032-­39493-0 (­hbk)

ISBN: ­978-­1- ­032-­21032-2 (­pbk)
ISBN: ­978-­1-­0 03-­3 4997-6 (­ebk)

DOI: 10.1201/­9781003349976

Typeset in Times
by codeMantra
 This edited book collection is dedicated to the families,
friends, colleagues, teachers, researchers, clients, consumers,
regulators, and everyone else who have directly and
indirectly supported and influenced the chapters’ authors
in their journeys while navigating work complexities,
celebrating successes, and reflecting on shortcomings.
Contents
Preface.......................................................................................................................xi
Editors.....................................................................................................................xvii
Contributors.............................................................................................................xix

Chapter 1 Human Impacts on Work Design..........................................................1

Graham Miller

Chapter 2 The Underestimated Value of ­Less-­Than-Ideal and Proactive

Ergonomic Solutions........................................................................... 13
Kym Siddons

Chapter 3 ­Return-­to-Work and 24/­7 Warehouse Operations............................... 27

Wenqi Han

Chapter 4 Designing a Visually Comfortable Workplace................................... 39

Jennifer Long

Chapter 5 Opportunities and Challenges for Designing Quality Work in

Residential Aged Care......................................................................... 51
Valerie O’Keeffe

Chapter 6 When Success Is Not Success, We Strive to Do Better...................... 65

Sara Pazell

Chapter 7 Reshaping Lifestyle Changes in a Heavy Weight World..................... 77

Keith Johnson

Chapter 8 Indian Farm Tractor Seat Design Assessment for

Driver’s Comfort................................................................................. 91
Bharati Jajoo

Chapter 9 ­Off-­The-Road Tyre Management: The Good, the Bad,

and the Ugly...................................................................................... 101
Paulo Gomes

vii
viii Contents

Chapter 10 The Human Factors Practitioner in Engineering ­

Contractor-Managed Investment Projects......................................... 111
Ruud Pikaar

Chapter 11 Deciphering the Knowledge Used by Frontline Workers in

Abnormal Situations.......................................................................... 127
Christopher M. Lilburne and Maureen E. Hassall

Chapter 12 The Tyranny of Misusing Documented Rules and Procedures......... 141

Nektarios Karanikas

Chapter 13 Creating Ownership and Dealing with Design and

Work System Flaws........................................................................... 153
Stasinos Karampatsos

Chapter 14 Stuck in a Holding Pattern: Human Factors Training

Development for Sports and Recreational Aviation.......................... 163
Claire Greaves and Reuben Delamore

Chapter 15 Undertrained Workforce and Poor System Designs.......................... 179

Jose S­ anchez-Alarcos Ballesteros

Chapter 16 The Ergonomics Consultants Lot Is Not an Easy One..................... 189

Rwth Stuckey and Philip Meyer

Chapter 17 Tread Softly Because You Tread on My Dreams: Reflections on

a Poorly Designed Tram ­Driver-Cab................................................. 203
Anjum Naweed

Chapter 18 Creating Conditions for Successful D

­ esign-­in-Use........................... 217
Lidiane Narimoto

Chapter 19 New Scientific Methods and Old School Models in Ergonomic

System Development......................................................................... 227
Thomas Hofmann, Deike Heßler, Svenja Knothe,
and Alicia Lampe
Contents ix

Chapter 20 It’s Only a Reporting Form............................................................... 243

Brian Thoroman

Chapter 21 SAfER Way to Design Work............................................................. 253

Maureen E. Hassall

Index....................................................................................................................... 273
Preface
Nektarios Karanikas

Sara Pazell

A FEW WORDS FROM NEKTARIOS

It was not long after the publication of the first edited book Safety Insights (­Karanikas
and Chatzimichailidou, 2020) that Sara, who kindly read it, approached me with the
idea to work together on a new edited book on Ergonomic Insights, the one you are
now holding in your hands or reading on your display. Although I had decided to
continue working on two monographs that I have been trying to put together for quite
some time, I could not resist the idea. Human Factors/­Ergonomics (­HFE) is an area
to which I feel very close. Not only because I studied this discipline at a master’s level
and since then has changed how I view the world. It is because it applies to all aspects
of human activities and interactions with our natural and ­socio-technical environ-
ments, whether this is our workplaces, social and public activities, house chores, etc.
However, the scope of this book is the work environment.
Sara’s suggestion to invite professionals and practitioners, HFE experts or not,
from our network and beyond to share their experiences, especially from work
design, greatly appealed to me. Open invitations were also the case with the Safety
Insights book, but this time the scope was wider. HFE and work design do not, or
should not, focus on safety alone. Work encompasses much more, and it is far broader
than considering (­un)­safe interactions and exposures. It is about human performance
and ­well-being at individual and collective levels while we generate deliverables and
offer services safely, with quality, efficiency, timely, and other important parameters.
It is equally about leveraging opportunities and managing negative risks, celebrating
successes, and reflecting and acting on failures.
As such, this project was born in ­mid-2021. Apart from the invitations we sent
to our network, sharing the project idea through LinkedIn and the Human Factors
and Ergonomics Society of Australia (­HFESA), who kindly supported our initiative,
attracted more interest than what we had anticipated. Even more exciting was that
several of the chapter proposals came from multiple authors, different industries,
various regions, and diverse HFE applications.
To add some more enthusiasm, Taylor & Francis, after we agreed on this proj-
ect, invited us to launch a book series entitled Workplace Insights.1 The Safety
Insights and Ergonomic Insights books are now nested under this series, and Sara
and I wholeheartedly welcome interesting proposals for monographs or edited books
for the same series. Sara has already started working with another colleague on an
edited book for Healthcare Insights! Your proposal can be about specific industry
sectors or w­ ork-related disciplines such as occupational hygiene and occupational

1 https://­www.routledge.com/­­Workplace-Insights/­­book-series/­CRCWIRWHSWHPC

xi
xii Preface

health. I hope this book will inspire you enough to set sails for your own editing and
authoring adventure in our series.
After a long journey together with the 24 other contributors, whom I deeply thank
for their patience with me, we are proud to present you with a great collection of 21
engaging chapters, some of them more “­reflective” and others a bit more “­technical”.
Although you might feel inclined to focus on chapters closer to the industry/­discipline
of interest, we invite you to consider all chapters with the same curiosity as most, if not
all, of the cases presented offer insights and lessons that can be ­cross-transferred, pro-
vided that their “­translation” accounts for the targeted context (­Karanikas et al., 2022).
However, what is the big picture emerging from this book? This is what I asked
myself while writing those lines. I decided to employ technology and use my very
basic skills with the NVivo and Leximancer software to gain a grasp of the main
themes and their connections. As you can observe from the word cloud (­­Figure 0.1),
work and design appear most often, as expected. However, the terms systems, used,
required, and management emerged with about the same frequency. Something like
“­Work design is required to manage and use systems [successfully]”; this is how I
read it, but feel free to interpret it differently.
Interestingly, the next more frequently appearing words seem like suggest-
ing the principal parameters related to work design (­e.g. process, operations, risks,
safety, issues) or necessary to design work (­e.g. support, workers, change, training,

­FIGURE 0.1 Word cloud generated with Leximancer from all chapters.
Preface xiii

­FIGURE 0.2 Concept map generated with NVivo from all chapters.

organisation, good). The outer layers of words in the cloud can be viewed as ingre-
dients, preconditions, and contextual factors. The connections of all these terms are
illustrated more clearly on the concept map (­­Figure 0.2), which presents several paths
and interdependencies. I will refrain from expressing here what I see on this map.
I will leave this to you. I hope you can get back to these figures after reading each
chapter and check whether they make sense. Indeed, the words cloud and concept
map do not mean to give birth to new theories and replace existing ones. They just
represent the emerging picture of what 26 authors in this book have experienced and
decided to share with you!

A FEW WORDS FROM SARA

Storytelling is at the heart of learning and connecting with others. We are pleased
to present a collection of stories that reflect ­real-world scenarios of practitioners
devoted to the design of good work through human factors and ergonomics (­HFE).
xiv Preface

Importantly, we asked the authors to dismantle their experiences and reflect on their
struggles as much as their wins. The terms “­failures” and “­successes” in this book
title stem from this idea. These terms may seem binary and, as systems analysis and
designers, we understand things differently, dynamically, like resonance and altered
states of being that drift from or exceed expectations. However, we needed the linear
pull of “­bad” and “­good” to capture the attention of readers who want to learn about
avoiding pitfalls (­or navigating them) and achieving the wins.
It is the nuanced way in which the wins occur or the reasons why the struggles exist
that inform meaningful lessons. In some instances, these were founded in relation-
ships, communication styles, confidences held, or how work was aligned with crucial
­decision-makers and embedded within company strategy. Many times, restrictions
existed because of a constrained scope of work. An advisor cannot truly “­advise”
when the approach that has been set for them does not reflect what they would have
advised! Similarly, a designer cannot truly “­design” well when the constraints mean
that they are invited to address only a small part of one design phase.
Theoretically, the “­fit” of HFE to design good work is a perfect match. Human
factors and ergonomics provide a unique pathway to view the world from the perspec-
tive of the user: How does it work, what must I do to make it work, what effect does
it have on me, and how can I thrive given these environmental/­equipment/­tooling/­
systems? Skilled students, practitioners, teachers, and researchers have worked to
attain a deep understanding about dynamic and integrated human aspects: biochem-
istry, physiology, kinesiology, psychology, cognition, and social systems to under-
stand the impact of work on human subjects.
I love the idea of human capability achieved through design: inspirations, cre-
ativity, interacting systems, motivations, capabilities, communication, ideation, cre-
ations, resolutions, implementation, getting “­our hands dirty”, and yes, sometimes
battle wounds beneath the shine. There are remarkable achievements that can result
when these approaches are used such as improved social systems, better health, safer
work, improved communication, environmental protections, economic advance-
ment, and productivity with the accomplishment of serious competitive market reali-
ties. “­Good work” must be designed well.
However, design can be clumsy and messy, and that sphere of uncertainty is not
always comforting. It requires empathy, and that takes patience, which is not read-
ily afforded when work requires rapid change. Sometimes, progress must be made
through small acts, baby steps, to help develop tacit knowledge about the methods
and the benefits. We ask business managers to bet on what is not known, and trust
in a design process. This can mean navigating unchartered territories and creating
unstable footing. Yet, we know that innovation is possible, given the right conditions.
Perhaps, through these stories, our readers will be encouraged by the successes
and empathise with the authors because of the challenges they encountered, know-
ing that clumsiness is part of the humility of living, learning, and growing. We know
that with each struggle, the only way is up, and up was the direction travelled by all
chapter authors. Their perseverance is what captivates me most. The authors were
challenged to walk through their experiences and tell their stories. As much as all
want to sing the praises of human factors and ergonomics, they agreed to share a
Preface xv

balanced view of their work: the roller coaster highs, lows, and side manoeuvres.
This was brave of them.
Nektarios and I wanted the rawness and richness of the “­day in the life of the
practitioner” to be expressed to the readers as a learning opportunity. Sometimes,
heavy in academia or technical jargon, there is a disconnect about how to apply what
is esoteric because it is embedded in theoretical models, and blend this into the daily
grind of the working world across any industry. The authors have managed to paint
pictures and describe their activities in diverse industries and places, like military,
aviation, transportation, agriculture, mining, oil and gas, sport and recreation, con-
struction, nuclear settings, control rooms, education, health care, office administra-
tion, and executive management. Bravo.
I thank my colleague and the lead editor on this book, Dr Nektarios Karanikas. I
have known Nektarios since he came to Australia and started teaching at his univer-
sity. He strives to make his mark, create a ripple, and foster change. Notably, among
other achievements, Nektarios started this literary series with the Safety Insights
book and, because I commended him on telling accessible practitioner stories, then
challenged him to consider the realm of opportunities with other topics that all affect
the workplace and its design, he urged me to join him in this book. I am thank-
ful for the learning opportunity. Taylor & Francis spurned this on and encouraged
Nektarios and me to support a series. We look forward to other books on the horizon
but, for now, we celebrate the accomplishments of this one: A celebration of human
factors and ergonomics through the telling of the stories of the people that make it
come alive.

REFERENCES
Karanikas, N., Shanchita, R. K., Baker, P. R. A., & Pilbeam, C. (­2022). Designing safety
interventions for specific contexts: results from a literature review. Safety Science, 156.
DOI: 10.1016/­j.ssci.2022.105906
Karanikas, N., & Chatzimichailidou, M. M. (­2020). Safety Insights: Success & Failure Stories
of Practitioners (­edited book). Routledge: Boca Raton. ISBN ­978-­0 -­367–­44572-0, DOI:
10.4324/­9781003010777
Editors
Dr Nektarios Karanikas is an Associate Professor of Health, Safety, and
Environment at the School of Public Health and Social Work, Faculty of Health,
QUT. He was awarded his doctorate in Safety and Quality Management from
Middlesex University (­United Kingdom) and his MSc in Human Factors and Safety
Assessment in Aeronautics from Cranfield University (­United Kingdom). He holds
engineering, health and safety, human factors, and project management professional
credentials and has been an active member of various prestigious international and
regional associations.
Dr Karanikas g raduated from the Hellenic Air Force Academy as an aeronautical
engineer and worked as an officer in the Hellenic Air Force for more than 18 years
before he resigned at the rank of Lt. Colonel in 2014. While in the Air Force, he
served in various positions related to maintenance and quality management and acci-
dent prevention and investigations, and he was a lecturer and instructor for safety and
human factors courses. After his resignation, he started his ­full-time academic career
as an Associate Professor of Safety and Human Factors at the Amsterdam University
of Applied Sciences between 2014 and 2019.
Dr Karanikas has published numerous academic journal articles, including papers
in ­top-tier journals, ­peer-reviewed conference papers, and chapters, and has been
invited to speak at several international and regional summits and workshops. In
2020, he published a c­ o-edited book titled “­Safety Insights: Success and Failure
Stories of Practitioners”. He is an Associate Editor for Safety Science and a member
of editorial boards and a regular reviewer of safety and human f­actor-related jour-
nals. He also volunteers in various activities of professional bodies in Australia and
internationally.

Dr Sara Pazell i s a work design strategist and the managing director for ViVA health
at work (­work design specialty consultancy), working across all industries. This has
operated for more than 17 years in Australia, helping clients solve ­real-world chal-
lenges and design “­good work”. Sara was awarded her doctorate in Human Factors
and Ergonomics from the University of Queensland through the Sustainable Minerals
Institute, her Master of Business Administration with a major in International
Business Development from the University of La Verne, California, and her Bachelor
of Occupational Therapy from the University of South Australia. Sara has managed
business development projects in Australia, Southeast Asia, and the United States,
including assuming roles as an administrator and executive director of healthcare
organisations.
Sara holds affiliations with five Australian universities, including that as
an Industry Fellow with the Sustainable Minerals Institute at the University of
Queensland. Sara provides teaching and research support in organisational science,
business management, human factors, ergonomics, health and wellness, safety, and
allied health. Sara is part of the international advisory committee for the WELL

xvii
xviii Editors

Movement concept v2 and an expert faculty member for Australia’s only certified
Wellness WiseTM Practitioner training programme. Sara was the committee chair
for the Human Factors and Ergonomics Society of Australia’s Good Work Design
position paper and supporting resources. Her other passions include instructing yoga,
sports, and strength and conditioning.
Contributors
Reuben Delamore Nektarios Karanikas
Tactix Group Queensland University of Technology
Sydney, Australia Brisbane, Australia

Paulo Gomes Svenja Knothe

Segurança Diferente Hochschule Osnabrück
Brisbane, Australia Osnabrück, Germany

Claire Greaves Alicia Lampe

Tactix Group Hochschule Osnabrück
Sydney, Australia Osnabrück, Germany

Wenqi Han Christopher M. Lilburne

Freelance consultant University of Queensland
Singapore Brisbane, Australia

Maureen E. Hassall Jennifer Long

University of Queensland Certified Professional Ergonomist
Brisbane, Australia Sydney, Australia

Deike Heßler Philip Meyer

Hochschule Osnabrück Freelance consultant
Osnabrück, Germany Victoria, Australia

Thomas Hofmann Graham Miller

Hochschule Osnabrück Humans Being At Work
Osnabrück, Germany Brisbane, Australia

Bharati Jajoo Lidiane Narimoto

Body Dynamics EWI Works Inc.
Bengaluru, India Edmonton, Canada

Keith Johnson Anjum Naweed

Fulton Hogan CQUniversity Australia
Eight Mile Plains, Australia Adelaide, Australia

Stasinos Karampatsos Valerie O’Keeffe

Hellenic Air Force Flinders University
Cholargos, Greece Adelaide, Australia

xix
xx Contributors

Sara Pazell Kym Siddons

ViVA health at work Kym Siddons Physio
Sunshine Coast, Australia Adelaide, Australia

Ruud Pikaar Rwth Stuckey

ErgoS Human Factors Engineering La Trobe University
Enschede, Netherlands Melbourne, Australia

Jose ­Sanchez-Alarcos Ballesteros Brian Thoroman

Factor Humano Queensland Rail
Valladolid, Spain Brisbane, Australia

The contributors would like to note: The cases and perspectives shared in the chap-
ters of this edited volume do not necessarily originate and/­or reflect the authors’
current employer and any other organisation, committee, or group with which the
authors might be affiliated.
 1 Human Impacts on
Work Design
Graham Miller
Humans Being At Work

CONTENTS
Masked Work Design Issues.......................................................................................3
Underestimating the Politics.......................................................................................5
Why Was That?...........................................................................................................8
The Lessons for Work Design and Beyond.......................................................... 10
Organisations Comprise Rational (­Mostly Visible) and N ­ on-Rational
(­Mostly Invisible) Elements................................................................................. 10
Work Design Is Synonymous with Organisational Change................................. 10
All of Us Bring Our ‘­Family of Origin’ Issues to Work...................................... 11
Egos Can Jeopardise Success............................................................................... 11
Personal Reflection Is Powerful........................................................................... 11
Final Thoughts..................................................................................................... 11
Bibliography.............................................................................................................. 12

Organisations are as complex as the people in them. I have been working in, con-
sulting, and studying organisations for decades, and I’m still often mystified by how
organisations function and which ingredients, when mixed, deliver effective and suc-
cessful organisational ­outcomes – or not. No doubt there could be many reasons for
this, but one would be that organisations are both ‘­rational’ and ‘­­non-rational’. This
alleged dichotomy, in part, underpins my ‘­success’ and ‘­failure’ stories below and,
therefore, deserves some explanation.
I suspect that many of us see ourselves, and by extension our organisations, as
‘­rational’ entities where plans are developed, research is undertaken, information is
assessed, decisions are made based on logic and data, strategies are implemented, and
performance is tracked. This perspective reflects what we describe as the ‘­classical’
view of organisations, where centralised leadership addresses discrete issues and
undertakes technical/­­non-political activities, and where performance is measured by
comparing outcomes against intentions (­Dufor & Steane, 2006).
On reflection, this rational/­classical perspective is my subconsciously predomi-
nant ‘­default’ position on how organisations work or should work. As a student of
Total Quality Management in the 1990s, I developed a strong affinity for ‘­processes’
by documenting, monitoring, and improving them. The ­Plan-­Do-­Check-Act (­PDCA)

DOI: 10.1201/9781003349976-1 1
2 Ergonomic Insights

model1 and the ‘­process determines outcome’ mantra made absolute sense to me, and
still do. Although this rational/­classical perspective of organisations feels ‘­right’ and
comfortable to me, I realise that, like everyone, I have biases and blind spots and rec-
ognise that there is probably more to the story. After all, organisations are made up
of humans, some of whom make important organisational decisions one minute and
stockpile toilet paper during pandemics the next! Marketing professionals tell us we
humans mostly decide based on emotions, although often disguised as logic, rather
than reasoning. Surely, this must play out in organisational life, mustn’t it?
Counter to the rational/­classical view of organisations, Mats Alvesson and Andre
Spicer suggest that organisations are, indeed, mostly ‘­­non-rational’. Their evocatively
titled ‘­­Stupidity-Based Theory of Organizations’ (­Alvesson & Spicer, 2012) claims
that most managerial practices are adopted based on faulty reasoning, alleged wis-
dom, and a complete lack of evidence. A core of this theory is an assertion that
although contemporary ­knowledge-based organisations claim that their ‘­intellectual
assets’ are their greatest resource, ­non-rational thinking, including power and domi-
nation, restricts the ‘­intelligent mobilization of cognitive capacities’. This is because
of organisational norms; we avoid asking tough questions and searching for rational
answers so as not to embarrass or threaten managers. As a result, dialogue is discour-
aged, justifications for decisions are not requested or provided, and ‘­conformity’ is
rewarded.
The situation above, combined with organisational time constraints, breeds a lack
of curiosity and c­ losed-mindedness and minimises critical reflection. Consequently,
intelligent people working in organisations refrain from using their cognitive
and ‘­ reflexive’ capacity and engage in what the authors describe as ‘­ stupidity
­self-management’. The latter means putting aside doubts and reflexive concerns to
minimise dissonance and, instead, focusing on ‘­identity construction’ and career pro-
gression. In doing so, organisations undermine the latent knowledge and intellectual
capacity that resides within. As a result, poor d­ ecision-making prevails and critical
issues, including sanctioned immorality and questionable ethics, go unchallenged.
When I first heard of the ­Stupidity-Based Theory of Organizations, my ratio-
nal ­perspective-loving self was sceptical. However, recent Royal Commissions in
Australia provide technicolour examples of the very issues that the theory high-
lights. During Australia’s Banking Royal Commission, an exchange between the
Commission’s senior counsel and the Commonwealth Bank’s new Chief Executive
Officer (­ CEO) confirmed that the Commonwealth Bank’s auditing department
had advised the Board in 2015 and 2016 that the bank’s ATMs were breaching
­anti-­money-laundering and ­anti-terrorism laws. Despite this being a ‘­red rating’, they
did nothing about it. In the same exchange, it was revealed that the new CEO had
challenged his boss at that time (­i.e. the former CEO), about selling customers ‘­junk
insurance’ when the bank knew about scandals and repayments for similar products
in the United Kingdom. The b­ ack-then boss advised the n­ ow-new CEO to ‘­temper his
sense of justice’ (­Ziffer, 2018).
So, is perhaps my rational perspective of organisations a little naïve? Perhaps
organisations are a blend of rational and n­ on-rational elements, and I have a bias

1 https://­asq.org/­­quality-resources/­­pdca-cycle
Human Impacts on Work Design 3

towards adopting a predominantly rational perspective of organisations. If this is the

case, what does this mean for my approach to work design? Reflecting on my success
and failure stories below may shed light on this.

MASKED WORK DESIGN ISSUES

Some years ago, I was working in an organisational development role for a govern-
ment agency. It was a great job, working with various teams to introduce significant
change programmes, facilitating planning workshops, managing the quality pro-
gramme, training project teams to implement organisational process improvements,
and implementing ­self-managed work teams.
One afternoon, a senior manager contacted me and invited me to discuss a prob-
lem they were having with one of their teams. They explained to me that the recep-
tion team, a small team of four people, was experiencing personality conflicts that
had been brewing for some time. The senior manager gave me a brief history lesson
on the team and its members, and a ­r un-down on what they thought was going on,
and who they suspected was the key protagonist. The senior manager asked me to
work with the team to resolve the issue. I left that meeting with the impression that
the senior manager expected that the solution to this apparent personality conflict
may involve relocating the suspected protagonist.
I subsequently met with the team and, while maintaining confidentiality, told them
as honestly as I could that I was meeting with them to seek their feedback on what
they saw as the issues and help them resolve these. I also asked what their assump-
tions were about why I was meeting with them. From their responses, it appeared that
my ‘­arrival on their doorstep’ had not been effectively communicated, and their key
assumption was that the senior manager appointed me to investigate them and report
my findings back. I reassured the team members that my primary intention was to
help them identify and address issues to help improve their life at work if they were
willing to do this.
All four members agreed that there were issues. After some initial hesitancy, all
agreed to engage in a discussion to reach a resolution. I asked each of the team mem-
bers to explain the situation and the issues from their perspective and sought agree-
ment from all in the group to let their colleagues speak, uninterrupted, and to ‘­just
listen’, which they agreed to do. While each member of the group spoke, I recorded
the discussions on a mind map on a whiteboard. This visual representation of their
conversation helped to ‘­paint a picture’ of their situation and the perceived issues
influencing their situation and provided a focal point for the conversation.
The discussion exemplified the value of mind mapping. The visual focus of partic-
ipants is on the mind map rather than solely on each other or the floor in particularly
uncomfortable situations seems to encourage more open dialogue. Translating the
spoken word into a visual representation helps tie the various conversation ‘­threads’
together, providing clarity to what might otherwise appear to be a rambling conversa-
tion. The visual representation of the spoken word also prompts inquiring questions
to clarify potential misinterpretations. As the map develops, themes and key issues
become more obvious. And asking ‘­what are you seeing here?’ can spark a whole
new round of conversation and potential collective insight.
4 Ergonomic Insights

At times, the discussions were passionate, but team members showed a willingness
to engage meaningfully to resolve the issues. Having an independent facilitator to
help guide the discussions was, I believe, critical because this provided team members
with a ­non-threatening and impartial listener with whom they could make eye con-
tact while still communicating with their colleagues. I paraphrased their comments
and asked questions to help clarify communications among the team members. After
everyone had spoken, I asked the group what they were seeing on the whiteboard.
What were their common themes or connections? What were the key issues emerg-
ing? From there, I asked the group about how these issues could be best addressed.
These discussions confirmed that the team of four worked together each day
to manage the reception function (­triaging clients, processing applications, etc.).
Although the team had a supervisor, the team was essentially s­ elf-managing. The
supervisor was geographically separated from the team and supervised a larger team
that was undergoing a significant systems’ change and consumed much of their time.
The reception team was a fresh addition to the supervisor’s responsibilities, because
of a recent organisational restructuring, and they had largely left the team to their
own devices.
The reception team members were technically competent and experienced and
could perform any of the required roles. This provided advantages of redundancy,
where all roles could be covered during staff lunch breaks or absences. However,
there was no job role roster. Which team member performed which role each day
was determined by who placed their bags and belongings on which chair when they
first arrived at work. This meant that whoever arrived earliest got more choice over
which roles they performed.
Team members confirmed that, in the past, there were occasional discussions
regarding who would perform which role that day. However, for unstated reasons,
these often had an uncomfortable undertone, and more recently, they rarely discussed
who was to perform which role. One team member admitted deliberately trying to
get to work earlier than others to have a broader choice of job roles that day. This
simple act highlights the importance of choice and ­self-determination in workplaces.
Daniel Pink posits that autonomy is one of three key work motivators: people want
to have control over their work. The other two are mastery (­i.e. people want to get
better at what they do) and purpose (­i.e. people want to be part of something bigger
than themselves) (­Pink, 2009).
These discussions helped to ‘­clear the air’, and team members agreed that the
confusion around team roles and responsibilities, together with some untested and
incorrect assumptions about team members’ motivations, was a major contributor to
the recent deterioration in team relationships. The team agreed to develop a weekly
rotating roster where each person undertook a role for a week. The members also
agreed to support each other when work demands varied for each of the roles. These
simple structural changes c­ o-designed by the team members addressed the aggrava-
tion which had built up, and the team environment improved from that point forward.
This was a ‘­success’ story because of several reasons. First, all team members
shared a willingness to resolve their issues. Without this shared commitment, any
attempts by me would likely have been fruitless. Second, while acknowledging the
senior managers’ perspective on what they saw as the issues, I approached the task
Human Impacts on Work Design 5

with an open mind and tried to avoid preconceptions of issues and solutions. Adopting
a ‘­beginner’s mind’ promotes a broader perspective. Third, I was as transparent and
authentic as I could be with the team members, which demonstrated respect and
helped to establish early rapport and trust; this set the scene for them to do likewise.
Fourth, I genuinely listened to team members to develop an understanding of the
issues without judgement, which created an environment of honest disclosure.
Finally, team members developed their own solutions, which engendered their
commitment to implementing the solutions. The need for ­self-determination in
work is w ­ ell-documented and l­ong-known by behavioural scientists. McGregor’s
Theory X and Theory Y model, which was developed over 60 years ago, recog-
nises that ‘­the essential task of management is to arrange conditions so that peo-
ple can achieve their own goals best by directing efforts towards organisational
resources’ (­McGregor, 1960). Similarly, Chris Argyris has long argued that humans
have basic ‘­­self-actualising trends’, akin to plants seeking to reach their biological
potential (­Argyris, 1962). The implications of this for job design are significant,
and the importance of ­co-design in h­ uman-centred workplaces is s­ elf-evident. As
­world-renowned facilitator Roger Schwarz acknowledges, ‘­When people are involved
in ­decision-making, they have greater commitment’ (­Schwarz, 2017).
This experience taught me that poor work design can masquerade as something
else. In this case, a lack of ‘­rational’ workplace structures in the form of no clear role
allocations resulted in ambiguities and led to a ‘­­non-rational’ response of poor team
communication resulting in workplace tension, which was attributed to ‘­personality
conflicts’.

UNDERESTIMATING THE POLITICS

As a management consultant, I was engaged by a government agency to design an
‘­integrated operations’ approach to better incorporate its key operations. Consultants
are often engaged when an organisational stalemate is reached, and, although I was
unaware at the time, this was the situation in this case. The organisation had contem-
plated developing a more integrated approach to several of its operations for some
years. However, previous attempts to better integrate ‘­like’ operations had struggled
to gain sufficient ­executive-level agreement and commitment.
Six months prior to my engagement, the organisation had established an inte-
grated operations steering committee comprising the organisation’s senior leaders.
The committee had met several times to discuss integration concepts and options
and had identified which parts and processes of its operations they could reorganise
to enable a more integrated approach to some of its key business. At some point,
the steering committee concluded that external help was required, and they scoped
the terms of my consulting engagement. As part of my engagement, I was to report
progress monthly to the steering committee on each of the identified process areas.
The client described the project as ‘­process consolidation’, but I saw it as an organ-
isational change project. Although the client never described this as a ‘­work design’
assignment, it very much was.
Soon after my engagement, I recognised an inconsistent use of language. Some
senior leaders used the term ‘­ coordinated operations’ rather than ‘­ integrated
6 Ergonomic Insights

operations’, and these terminology inconsistencies indicated to me potential differ-

ences in understanding. In addition, there appeared to be an incoherent understand-
ing of what the integrated operations ‘­end game’ looked like. This was surprising,
noting that they had considered the concept for several years prior to the project
commencing, and they had established the integrated operations steering committee
for six months.
Consequently, an early priority for me was to resolve this apparent mismatch
of views and understanding. I developed a concept of what ‘­integrated operations’
might look like, with definitions and potential pathway options showing the potential
phases of implementation, from partial to fully integrated operations. This was based
on an amalgam of views that had been provided to me through discussions, blended
into a synthesised, tangible concept proposal for discussion. I presented this concept
document to the steering committee with an expectation that this would generate
discussion, expose any differing views, and build a common understanding among
the group of what integrated operations could look like in reality. The steering com-
mittee’s discussion on my proposed concept and road map was underwhelming.
Although there was surprisingly little debate, I left the meeting with tacit approval to
proceed to ‘­Phase 1’. Ahh, success!
A large part of this project involved me facilitating stakeholder workshops,
including process redesign scoping workshops with relevant stakeholders to identify
and validate the processes identified by the steering committee. Through these work-
shops, two of the identified processes were deemed unsuitable for a redesign. The
steering committee subsequently accepted these recommendations. Partway through
this, a key senior executive retired unexpectedly for family reasons. This provided a
catalyst for a subsequent amalgamation of two divisions into one, which provided a
welcomed revised structural platform for a more integrated approach to key parts of
business operations. More success!
I continued working with various stakeholders to scope the process changes
required to make integrated operations a reality. I formed process redesign proj-
ect teams for the identified projects comprising a cross section of ­mid-level manag-
ers from across the organisation. Over a t­wo-month period, I facilitated redesign
workshops to identify current process arrangements, responsibilities and outputs,
and preferred future options. These ­operational-level workshops and meetings were
productive, with team members showing collaboration and genuine commitment to
adopting a more integrated approach. Constructive solutions to complex problems
were created, and implementation plans were agreed upon and developed. Even more
success!
The project also identified several complicated issues which needed to be
addressed at an organisational level, including changes required to the legacy IT
systems and changes to staffing categories and entitlements outlined in current enter-
prise agreements. Upcoming enterprise agreement negotiations provided an opportu-
nity for the organisation to incorporate new integrated operations requirements into
the new agreements.
Nevertheless, although the project was progressing well at the operational level, I
found it difficult to engage meaningfully with e­ xecutive-level stakeholders. Steering
committee discussions were often superficial. These meetings were ­ one-hour
Human Impacts on Work Design 7

duration, held monthly, and chaired by the deputy CEO. They were relatively formal
affairs, and discussions were ‘­respectful’. Committee members were busy executives,
predominantly males, and therefore with limited diversity, who were also engaged in
other significant concurrent organisational change projects.
Whether committee members had read the information I was tabling at the com-
mittee meetings was unclear. Even though much of the material I presented to the
committee was, at least in my mind, pivotal and important, discussions were gener-
ally brief and dispassionate. Questions were few. The only female committee mem-
ber occasionally asked insightful and interesting questions, which helped to add
some spark to the discussions. However, to me at least, she appeared to be a lone
voice of interest and concern. Often, other committee members did not engage in
conversations. Meeting time constraints meant that discussions on key issues were
often left unresolved, which I had to resolve later with the project sponsor.
The project continued, and in consultation with relevant stakeholders, the project
produced redesigned processes with revised accountabilities, new policies and pro-
cedures, and implementation plans for each of the revised processes. This provided a
blueprint for how the organisation would implement an integrated operations model
via a staged approach. Success continues!
During this development work, personnel changes meant that my reporting lines
changed, and my key contact became the person who was earmarked to oversee the
implementation of the new arrangements I had developed under the design phase.
I found this person difficult to engage; it was hard to find time to discuss issues.
There was a lack of feedback on key documents. The person was speaking in riddles
and demonstrated differing interpretations of the design concepts. As ­long-term staff
members who had progressed through the management levels, senior managers were
technically oriented. They did not convince me that they were sufficiently commit-
ted to the agreed way forward or had the appropriate temperament to manage the
human resource issues required for the successful implementation of an organisa-
tional change of this magnitude. Success diminishing!
In addition, it became increasingly apparent that the commitment of some senior
executives began to waiver on the details of some of the more challenging elements,
including negotiating with unions the proposed changes to employee classifications
and roles in the new enterprise agreement. I sensed that there were clouds developing
on the work design implementation horizon. Success diminishing further!
After my engagement ended, the organisation recruited a ­full-time project man-
ager to help manage the implementation of the initiative of the integrated operations.
This appointment coincided with the departure of the previous project sponsor. I had
no conversations or handover discussions with the incoming implementation man-
ager. Later, informal reports indicated the organisation has made some progress with
the implementation. However, several of the details developed under the design proj-
ect were amended, some elements of the implementation were curtailed, and several
key people in the organisation had moved on. Success becomes failure!
As Schwarz reminds us ‘­The finish line is not when you and the group have
made a decision; it’s when the decision has been implemented effectively’ (­Schwarz,
2017, ­ p. 82). Yes, the design component of the project provided the required
‘­rational’ outcomes, but these were not enough to ensure that the project delivered
8 Ergonomic Insights

what was intended. There are always multiple contributors to project failure or
­under-performance. In this case, the broader organisational issues contributed to this
­sub-optimal outcome, including the ‘­shifting sands’ such as key personnel changes,
and political issues that seemed to play out at the senior level. However, I was also
a contributor because I failed to acknowledge or address the ­non-rational influences
and political issues playing out at the senior level.
While I developed a proposed concept of integrated operations which the steer-
ing committee endorsed, key learning from this is that endorsement does not equal
commitment. This issue required a dedicated discussion rather than incorporation
into an already busy committee meeting agenda, hoping it got ‘­a tick’. The apparent
lacklustre level of support from steering committee members should have been a red
flag for me, but it was not. Instead, my ego allowed me to believe that I had developed
a solution to an apparently intractable organisational problem, and the steering com-
mittee’s endorsement of this solution meant that my worth was proven!
I worked closely with m ­ id-level managers as part of the project; however, my
engagement with the senior leaders was predominantly through monthly steering com-
mittee meetings. This approach did not engender genuine commitment from steering
committee members. The design solution I proposed was mine, not theirs. As with
all significant work design projects, senior executive commitment is critical. Gaining
genuine ­executive-level support for the project would, at the very least, have required
more robust discussions to understand the thinking of the committee members and
tease out an agreed position that all senior executives supported. Alternatively, I could
have engaged the committee in a facilitated discussion to develop their own agreed
position on the ‘­integrated operations’ solution. I believe this would have increased the
chances of organisational success. I could also have engaged more meaningfully with
senior leaders at critical points during the project, for example, through ­one-­to-one
meetings, to explore their concerns or perceived issues.
On reflection, I attribute my contribution to the project’s failure to not acknowl-
edging or addressing the ­non-rational issues that emerged. The question is why was
that? Writing this chapter prompted me to reflect on this, and I think perception is
the answer. Perception matters because the way we perceive organisations will deter-
mine what we see. What we see as important is what we gravitate towards.

WHY WAS THAT?

A model that has helped me make sense of the ‘­why was that’ question is Bolman and
Deal’s ‘­four frames’ model (­Bolman & Deal, 2021). This model identifies four lenses,
or ‘­frames’, through which we can view organisations:

• a structural frame, characterised by goals, tasks, roles and responsibilities,

metrics, etc. This broadly aligns with the rational/­classical perspective of
organisations mentioned above.
• a human resource frame, characterised by employee needs, professional
development, job satisfaction, etc.
• a political frame, characterised by personal agendas, power plays, coali-
tions, etc.
Human Impacts on Work Design 9

• a symbolic frame, characterised by motivating staff, visioning, celebrating

victories, creating purpose and meaning, etc.

These four frames provide a broad, holistic perspective of organisations. Although

this model was developed to inform organisational change programmes, it helps to
explain the rational/­­non-rational dichotomy, where some frames reflect a rational
orientation, and some reflect a ­non-rational orientation. On examination of the four
frames, I recognised that I have a natural affinity for the structural frame. It is my
preferred perspective for the reasons discussed above. This is probably unsurprising
for someone who has spent 20 years in the military and who consults in the predomi-
nantly rational areas of planning, risk management, emergency management, and
business continuity. As I see myself as a people person, I also identify closely with
the human resource frame. I’m often described as a good listener; I enjoy hearing
people’s stories and I rate job satisfaction as critically important for organisations
and the people in them. The symbolic frame is something I can identify with, too. I
see creating purpose and meaning as important if we do it authentically and without
‘­hype’.
However, the political frame does not resonate with me; it is my least preferred
frame. I have always had a mild disdain for organisational politics. I much prefer it
when everyone gets along and works together harmoniously. I value transparency,
diversity, and teamwork, and I see no value in power plays and personal agendas.
However, I recognise that not everyone shares this view. I recall a colleague once
telling me how much they loved the ‘­cut and thrust’ of working in the minister’s
office, and I remember thinking, ‘­that’s not for me’. For me, the political frame is
synonymous with agitation, confrontation, and potential conflict, and I don’t like
confrontation or conflict.
On reflection, I attribute my aversion to confrontation and conflict to my child-
hood experiences. My childhood observations told me that my father was uncomfort-
able with confrontation and conflict, and I am too. In the household I grew up in,
avoiding confrontation and conflict became a useful survival strategy that I subcon-
sciously honed from childhood. These principles have followed me into adulthood,
and now, I have a lifetime of cleverly but unconsciously developed strategies to help
me avoid confrontation and conflict. I’m often described by others as amenable and
­easy-going. On the ‘­Big Five Personality Test’,2 I rank high in the agreeableness fac-
tor. These seemingly laudable traits of mine reduce the risk of confrontation and con-
flict and help me feel flummoxed and my brain slow down. I believe that my aversion
to the political frame and its perceived association with confrontation and conflict
shines some light on why my success story was a success, and why my failure story
was a failure.
In my success story, the team members conflicted with each other because of
a structural issue. Dealing with rational structural issues is my sweet spot. In this
environment, I was in my happy place. Thankfully, the team members agreed to talk
things through rationally, which I envied, and the discussions resulted in a favourable
outcome. Great. This experience reinforced for me that I am an extremely competent

2 https://­­bigfive-test.com/
10 Ergonomic Insights

group facilitator in the right circumstances. Had the team members not agreed to
work through their issues rationally and had things gotten out of hand, my con-
flict aversion would probably have kicked in and my facilitation prowess may have
deserted me. If this had happened, it is likely that this experience would not have
been one of my success stories.
My failure story is even more enlightening. I approached this assignment with my
predominant rational, structural perspective on high beam. There were lots of struc-
tural issues to address, and I did just that. I engaged with eager people and facilitated
­operational-level workshops to develop improved rational structural arrangements.
This solution addressed what the organisation had been struggling with for some time.
However, there were also some important ­non-rational political issues at play with
senior members of the organisation and with the person who would implement the
redesigned organisational structures and processes. My aversion to the political frame
and my natural inclination to avoid confrontation and conflict meant that I underesti-
mated these important ­non-rational issues. However, a more honest assessment would
attribute this to the fact that I felt intimidated by the senior leaders. Challenging or
confronting them in steering committees or elsewhere was not something with which
I felt comfortable. I just did not want to move to this space, so I didn’t. As a result,
what could have been a successful work design project became a failure story.

The Lessons for Work Design and Beyond

We can all learn from our successes and failures. Some lessons link to a specific
experience, and some are more ­broad-reaching that emerge multiple times across
different circumstances. If we learn these lessons well, hopefully, our future experi-
ences that may have otherwise ended up as additions to our failures list will end up
on our successes list. Below, I share some of my b­ road-reaching lessons that emerged
from all my success and failure stories.

Organisations Comprise Rational (­Mostly Visible) and

­Non-Rational (­Mostly Invisible) Elements
Our ‘­world view’ of organisations will impact our awareness of the interplay between
these elements, filtered through our preferences, biases, and blind spots. Being aware
of these filters will enable us to adopt a more holistic and complete picture of the
organisation we are working with and the work design requirements and issues. This
is particularly important for work design, which could arguably be seen as inherently
rational because of its scientific origins and predominant focus on structural issues.

Work Design Is Synonymous with Organisational Change

A successful work design project includes a successful design component (­largely
rational) and a successful implementation component (­largely n­ on-rational). The
implications of this are significant to work design success. The fact that ‘­organisational
politics can become a problem during times of organisational change’ (­McShane,
Travaglione, & Olekalns, 2013) suggests that the successful implementation of work
Human Impacts on Work Design 11

design initiatives will need to address both the rational and ­non-rational aspects of
organisations. Consequently, work design practitioners need to be acutely aware of
the organisational politics that could be at play if they want to see their work design
projects implemented as intended.

All of Us Bring Our ‘­Family of Origin’ Issues to Work

Our education in group dynamics starts at a very early age, in our family unit. This
is our first team experience. Our young and impressionable brains learn quickly how
teams and groups work and where we fit in them. This knowledge is later comple-
mented by lessons from the schoolyard. Through these experiences, we learn, for
example, how to deal with conflict, how to respond to compliments or criticism,
and how to persuade others to achieve our desired outcomes. For many of us, these
childhood lessons may not have reflected best practice, noting that they originated
from the courtesy of role models who were operating in accordance with their own
‘­family of origin’ programming. As a result, we may freeze when approached by a
boss who reminds us of a critical parent or unjustifiably resent a work colleague who
subconsciously reminds us of a disliked sibling. With all our ‘­family of origin’ issues
playing together in the workplace sandpit, it should be no surprise that some elements
of organisations are n­ on-rational! Developing our awareness of these hidden aspects
of ourselves can only benefit our workplace interactions and beyond.

Egos Can Jeopardise Success

The proverb ‘­pride comes before a fall’ applies as much to work design practitioners
and consultants as anyone. Our ego wants us to design a brilliant solution to a problem
and be lauded for our cleverness. However, successful work design solutions which
are implementable and are implemented require ownership from those impacted.
That means that effective solutions are as much about best fit as best practice. For
work design practitioners and consultants, this requires taking people on a journey,
and never losing sight that it is about them, not us. We must keep our egos ‘­in check’.

Personal Reflection Is Powerful

The pace of organisational life allows little time for reflection. However, reflection is
key to addressing each of the points above and more. ‘­How we spend our days is, of
course, how we spend our lives’ (­Hasson, 2020). If we want to live better lives, we
must live better days, and reflection can help us do this. Reflection can be achieved in
different ways (­e.g. engaging a counsellor or an executive coach, undertaking an ‘­action
learning’ process, journaling, and meditating), but it is a deliberate process. Reflection
will help uncover amazing things that are quietly floating just below the surface.

Final Thoughts
For me, writing this chapter has been a valuable reflective process. It has prompted a
discussion with my partner, who happens to be an executive coach, to help me make
12 Ergonomic Insights

sense of my subconscious beliefs that were formed courtesy of my ‘­family of origin’

experiences. A key part of this has been acknowledging my aversion to confronta-
tion and conflict and my apparent inability to manage this effectively. I have never
been trained in how to do this effectively. Instead, I developed an approach based on
­role-modelled avoidance. The downsides to this, of course, are many. One has been
a ­self-perception of being a ‘­­fair-weather’ facilitator. Another has been cognitive
dissonance around what I did or didn’t do and what I should have done. However,
through reflection, I now have a better understanding and, as a result, have adopted
a new mindset. This has been like turning on a light in a previously dark room. I
have made significant progress in only a short time, and this, I believe, has and will
continue to result in me being a more effective work design practitioner and a more
effective human. I highly recommend it!

BIBLIOGRAPHY
Alvesson, M., & Spicer, A. (­2012, June 21). A stupidity-based theory of organisations. Journal
of Management Studies Vol 59 number 3.
Argyris, C. (­1962). Interpersonal Competence and Organizational Effectiveness. Homewood:
Irwin.
Bolman, L., & Deal, T. (­2021). Reframing Organisations. Hoboken: Jossey-Bass.
Dufor, Y., & Steane, P. (­2006). Competitive paradigms on strategic change. Journal of Strategic
Change Vol 15 number 3.
Hasson, G. (­2020). Mindfulness Pocketbook. Chichester: John Wiley & Sons, Ltd.
McGregor, D. (­1960). The Human Side of Enterprise. New York: McGraw-Hill.
McShane, S., Travaglione, T., & Olekalns, M. (­2013). Organisational Behaviour. Sydney:
McGraw-Hill.
Pink, D. H. (­2009). Drive: The Surprising Truth About What Motivates Us. New York:
Riverhead.
Schwarz, R. (­2017). The Skilled Facilitator. Hoboken: Jossey-Bass.
Ziffer, D. (­2018, November 24). Banking royal commission exposing Australia’s business
leaders aren’t operating on a higher plane. Retrieved from ABC News: https://­www.abc.
net.au/­news/­2018-11-24/­banking-royal-commission-commonwealth-bank-bosses-not-
learning/­10549754
 2 The Underestimated
Value of ­Less-­Than-
Ideal and Proactive
Ergonomic Solutions
Kym Siddons
Kym Siddons Physio

CONTENTS
Temporary Solutions Could Work as Well!.............................................................. 15
Initial Assessment and Solutions.......................................................................... 15
Technical Misses and Remedies........................................................................... 17
The Crucial Missing Point................................................................................... 18
From Good to Almost Ideal...................................................................................... 19
From Good to Better............................................................................................ 19
From Better to Almost Ideal................................................................................. 23
Proactiveness Pays Off.........................................................................................24
References.................................................................................................................25

I have worked in private physiotherapy clinics for most of my 2­ 5-year career as a

sports and exercise physiotherapist. In ­mid-2015, I moved from overseas to a practice
located in ­inner-city Adelaide, Australia. I noticed that my clients from the surround-
ing offices and high schools came in to see me with different challenges. Several of
their physical complaints were related to conditions arising from poor work envi-
ronments and study habits. I noted that desk workers and students presented a high
incidence of low and ­mid-back pain, neck and shoulder pain, and headaches. Thus,
I began my journey into researching and upskilling in occupational health physio-
therapy with a focus on ergonomics.
My experience was backed by emerging research highlighting the significant
health risks associated with excessive sitting and poor workstation ergonomics. Such
evidence gave me hope and fuelled my determination to help spread the ‘­good news’
about the simple yet significant steps that organisational leaders and workers could
take to optimise the health of their employees and minimise the risk of i­ ll-health and
injury. This includes increasing workers’ capacity for o­ ffice-based work and limiting
their risks of incurring musculoskeletal injuries (­MSDs).

DOI: 10.1201/9781003349976-2 13
14 Ergonomic Insights

When working with elite athletes, our h­ igh-performance team of health profes-
sionals and coaches screened the athletes for injury risks, increasing athletic capacity
(­e.g. strength, power, flexibility, and skills) and managing their workloads to opti-
mise their performance and minimise their health risks. I realised that workers and
students might not have such a ­well-formed team of health professionals and coaches
on hand. However, I believe that it is invaluable to educate and empower them in
practical means to identify when they are at an increased risk of injury, ways to
increase their performance capacity, and methods to manage their workloads for bet-
ter health and productivity.
One means I find useful for the prevention and early intervention of musculo-
skeletal conditions is conducting ergonomic assessments that include a review of
workers’ workstations with subsequent recommendations and advice about posture,
movement, and targeted exercises. From a clinician’s point of view, by the time a
client comes to see me in the physiotherapy clinic, it is usually when their symptoms
have reached a point where their pain or dysfunction is significantly impacting their
daily life. Sometimes, the pain or dysfunction has built up over time, and the client
and I work through the factors that have contributed to their problem. In these cases,
assessing the environment in which they work, such as their workstation s­ et-up, is a
critical factor in managing their MSDs and implementing sustainable improvements.
Other times, the client’s symptoms or dysfunctions are acute. Even in this instance,
together, we can usually trace back the ‘­warning signs’ that their body wasn’t coping
well with the various loads it needed to sustain on a ­day-­to-day basis. We then focus
on improving their capacity to sustain these loads (­e.g. via combinations of strate-
gies such as targeted exercises and stretches, education, and manual therapies) and
changes that can be made to their environment to enhance their performance. This is
where optimising ergonomics within their work, while considering home and recre-
ational environments, is of utmost importance.
In addition to considering the physical needs of a worker or student, an enquiry
about their mental health is necessary (­WHO, 2000). Stress, anxiety, and depression
may affect them by slowing cognition and reducing job performance and productiv-
ity. This can also affect their physical capability and daily functioning (­Lerner &
Henke, 2008). Reviewing these factors is therefore key to conducting holistic ergo-
nomic assessments and making tailored, appropriate recommendations that will be
successfully implemented and sustained by both employees and employers.
Having read how ergonomic assessments consider both the physical and mental
health of an employee or student, it might seem obvious that conducting an ergonomic
assessment must be done with the person who uses equipment in their environment.
Yet I cannot tell you how many times ­well-meaning employers or organisations have
told me ‘­That person is away today, but can you still take a look at their desk?’ As
much as I aim to be obliging, the answer is ‘­No’. I cannot ask the user how they feel
physically and mentally during and after using their workstation. Nor can I objec-
tively assess how their body fits and moves within and around it. Ergonomics is not
about evaluating inanimate objects; it is about humans, and how they interact within
their work environment, and what they need to thrive.
Neglecting to assess and address the environment in which a worker or a student
spends most of their day undoubtedly puts their physical and mental health at risk,
Less-Than-Ideal and Proactive Ergonomic Solutions 15

can delay progress in the management of MSDs, or contribute to the recurrence of

health problems. An ‘­office sweep’ of ergonomic assessments by a trained profes-
sional is often very enlightening for employees and employers as we work together to
determine good work design that benefits individuals’ work outputs while enhancing
their physical and mental health. In the following cases, employees opted to have
their office workstations assessed.

TEMPORARY SOLUTIONS COULD WORK AS WELL!

Early in my professional journey, I performed ergonomic workstation assessments in
a large office for workers who ‘­opted in’ to have their workstations reviewed to gener-
ate improvement recommendations. These employees were offered the assessment,
and their participation was voluntary. There was one gentleman I’ll never forget. His
complaint to management after I assessed his workstation changed my approach to
my future work in ergonomics. While I was highly embarrassed at the time and keen
to remedy the situation urgently, I’m eternally grateful for those lessons learned.
When I entered his office, this man in his ­mid-thirties was friendly and eager to
see me. He went to great lengths to explain all the details of his previous injuries and
current levels of discomfort. He complained of low back pain which increased by the
end of the day and pain in both wrists and hands while typing. By using the Visual
Analogue Scale,1 I determined that this was ­low-grade pain intensity, rated at ­2–3/­10
typically and less than 5/­10 on most occasions. He reported mild tightness in the back
and forearms but minimal to no sensory changes such as pins and needles or other
physical or neurological symptoms.
I could immediately see several factors about his chair, desk, and screen s­ et-up
that might have been contributing to overload on his body. Further questioning about
his posture habits and how often he moved about during the workday also revealed
areas for improvement. He was not particularly active but did walk or jog slowly a
couple of times a week before or after work. Hence, we began the assessment, adjust-
ment, and education process.

Initial Assessment and Solutions

The client’s desk was of fixed height and his workstation was arranged so that the
chair and screen/­keyboard ­set-up was in the corner of a ­right-angled desk. His chair
had no arms but was unusually high and the seat pan was tilted forwards. While the
seat pan tilt helped the balls of his feet touch the floor, the client was unable to sup-
port any weight on his buttocks or recline against the backrest during the day. This
likely resulted in excess use, leading to fatigue of his back and neck muscles. It also
led to improper positioning of his shoulder blades because his arms reached forwards
so the shoulder blades were less effective in anchoring and providing support for his
arms.

1 https://­w ww.sira.nsw.gov.au/­­r esources-library/­­m otor-­a ccident-resources/­p ublications/­­f or-

professionals/­­whiplash-resources/­­whiplash-­assessment-tools/­­assessing-­pain-vas
16 Ergonomic Insights

Therefore, along with sitting for prolonged periods at his desk without regular
movement breaks, his chair position was a likely factor contributing to low back
strain and resulting pain as his workday progressed. Moreover, the forward chair tilt
also resulted in him leaning on his forearms, in fixed shoulder internal rotation while
typing. This likely increased the work of the wrist extensor muscles and inhibited
larger proximal muscle groups functioning optimally.
We adjusted his seat pan to a neutral position and lowered it slightly. We discussed
the benefits of positioning his body in the rear of the seat pan so that weight could be
taken through his pelvis (­i.e. via ‘­butt bones’ or ischial tuberosities) and his back against
the chair’s backrest, at least part of the time, to reduce strain on his back. Then, the
lumbar support needed to be adjusted to adequately fit his lumbar lordosis for comfort.
Once the chair was adjusted and he was positioned adequately to allow for the
relaxation of larger muscle groups, it was evident that a footrest was required. The
client’s feet were far from flat on the floor, so he quickly tucked them under his chair
to support them on the base. This brought his weight forward from the pelvis and
chair again. When I explained how this could sabotage his efforts to use his backrest
if sustained, he agreed that a footrest was likely a good option.
Moving the client’s workstation out of the corner position to along one side of
his desk allowed his elbows to move freely, rather than leaning on them for support.
Also, significant findings of an assessment of his desktop screen and accessories
showed that the computer monitor screen sat low on the desk, with his lower neck
and upper back flexed, the weight of his head much farther forward than his shoul-
ders and trunk, resulting in upper cervical (­neck) extension. Sustaining this position
for prolonged periods likely contributed to upper back and possibly arm pain, so we
repositioned the screen.
Temporary reams of paper were used to raise the monitor so that the ‘­working
part’ of his screen was approximately eye height and education was provided in alter-
native postures of the head and neck to reduce neck, back, eye, and arm strain. We
also discussed his keyboard and mouse positions, bringing them closer to his body to
avoid ­over-reaching. Now, his chair and desk ­set-up allowed resting his back, better
head/­neck position, and less need to lean on his arms. He reported that the keyboard
and mouse felt easier to use.
Finally, we recapped on moving more regularly, ideally, every ­20–30 minutes,
positioning himself to reduce strain on his back, neck, and arms often, before symp-
toms came on each day. Additionally, I prescribed a series of targeted stretches and
exercises for his low and ­mid-upper back, neck, arms, and hands. He practised these
with me. I left him with a d­ ouble-sided handout that had documented the movement,
posture, and exercise strategies that he was to focus on, with some pertinent notes
and reminders written down.
Twenty minutes had been allocated for each staff member’s ergonomic assess-
ment and included brief questioning about their physical and mental conditions relat-
ing to their work and workspace, along with the objective assessment, provision of
some posture and movement advice, and some preliminary adjustments. While this
gentleman’s assessment took double that time, by the end he was calm and comfort-
able with his new s­ et-up and the challenge of developing some new movement, pos-
ture, and exercise habits.
Less-Than-Ideal and Proactive Ergonomic Solutions 17

In my detailed report, I outlined the assessment results, changes made, and educa-
tion provided during the session, and I stated ‘­future recommendations’. These rec-
ommendations included a large, sturdy, carpeted, and ­height-adjustable footrest plus
a permanent monitor raise. Based on his low to moderate grade symptoms and the
two pieces of equipment recommended, I assessed his needs as a ‘­moderate priority’.

Technical Misses and Remedies

At the end of the day’s assessments, I chatted with the ‘­People and Culture Manager’
to summarise a few clients with h­ igh-priority needs. There were several workers in
this office with unsuitable workstations coupled with high and dysfunctional pain
levels, so we mainly discussed plans of action to help them as soon as possible.
Nevertheless, it seemed remiss in hindsight that I failed to draw more careful atten-
tion to the client’s case described above, and I only assessed him as a ‘­moderate
priority’ for implementing recommendations. On reflection, his reported lower levels
of pain ­pre-assessment, the changes made that reduced physical strain, and the result-
ing comfort at the end of the session were the main reasons that I didn’t prioritise his
needs as ‘­high priority’ or urgent.
Within a week of the assessment, I received a phone call from the People and
Culture Manager explaining that this client had approached her complaining of
increased wrist and hand pain. I immediately emailed the client to schedule a time
to review with him the soonest possible time and reassured him that we would find
a solution. I attended the office the next day and spoke with the manager and the cli-
ent. I asked if any of the recommendations had been implemented yet for any of their
employees. I was, naively, surprised to hear that they had not.
The client had become anxious about the wrist and hand pain, even though it
hadn’t increased beyond his previous pain levels but hadn’t improved much either.
He had expected that it would disappear quite quickly. I also noticed that I hadn’t
lowered the tabs on his keyboard at the time of our initial assessment, which we then
raised. Lowering the tabs subsequently reduced the degree of his wrist extension dur-
ing typing and improved his comfort.
I also recommended that he trial a k­ eyboard-length gel wrist support to reduce
contact stress on his wrists during typing. We discussed various alternatives for
mouse use (­e.g. vertical, contour, or ­roll-bar mouse), but he was not keen to try those
in the first instance due to poor results previously. Furthermore, after realising that
the lack of footrest discouraged him from positioning himself back in the chair and
using the backrest, I hunted down a temporary one. A sturdy box approximately the
right height for him to support his feet flat increased his comfort when sitting and
served as an interim footrest.
We also reviewed his stretches and exercises. Some of them were being done too
vigorously and slightly incorrectly, so modification and reiteration of key points helped
­fine-tune their performance. While we didn’t video them in this instance, I’ve found
that using a client’s smartphone for videoing exercises helps provide a more accurate
reference. I spoke with the manager, and we ordered the necessary footrest and key-
board wrist support immediately. The monitor raise was deemed more of an aesthetic
feature rather than of urgent functional need, so it was not considered a high priority.
18 Ergonomic Insights

The ­follow-up via a phone call the next week was positive. The new footrest and
wrist support were in situ, and the client was happy with them. His symptoms were
infrequent and less intense, so he felt that the changes were successful. He also
reported being more diligent with movement breaks and doing his stretches/­exercises.
I provided another ­follow-up via email a couple of weeks later and confirmed the suc-
cess of his interventions. The client felt that his s­ et-up, healthier posture, and exercise
habits were responsible for the absence of back and arm pain. He was happy for me
to carry on independently with the option to contact me always open. I reported this
to the manager, and we were both happy with his results.

The Crucial Missing Point

Despite the additional interventions that led to dramatic improvements for the cli-
ent, I realised that I had not considered psychological risk factors that would likely
have improved his experience ­post-assessment and in the interim before the ‘­further
recommendations’ were implemented. Since this assessment, I learned to take more
notice of the client’s psychological status and note any risk factors that warrant pri-
oritising their ­follow-up.
The flags that indicate the need for f­ollow-up can be varied but can commonly
present as apparent resistance to change; overt concern or anxiety about the symp-
toms or injury, including providing excess details about their injuries; use of nega-
tive language or verbal and n­ on-verbal expression about workstations, culture, or the
organisation; and reporting their excessive workloads, both physically and mentally,
or their conflicting demands. Health professionals often refer to such risk factors as
‘­red flags’ as they could potentially be more serious or complex to manage. I now
report these clients as ‘­higher risk’ and recommend that they be followed up with
‘­high priority’.
Change management and workplace culture are also areas that I find that need
to be approached with caution. Being sensitive to the climate of the workplace, the
employees within it, and the openness of management to receive recommendations
and act on them is also important. Examples of this might be a ‘­stressful’ environ-
ment that covertly discourages workers from movement breaks as they are seen to be
‘­not working hard’ or management that, for various reasons, resists spending money
on adequate furniture or accessories to support their employees’ ­well-being.
I have come to expect that it may take organisations a bit of time to implement
changes, even in ‘­urgent situations’. Understanding this has prompted me to ensure
that I talk clients through the things that they can do meanwhile, including moving
regularly, stretching, and exercising, adjusting their posture, and positioning. I try to
provide pertinent specifics per a handout that includes these tips and exercises along
with the ‘­further recommendations’ that I will make based on their assessment find-
ings. In many cases, employees are not privy to their assessment reports. Hence, oral
and written communication cements the information that we discuss at the time of
assessment for their ongoing reference.
I ask them to keep open lines of communication with their employers and let them,
or me, know if they have any questions or concerns p­ ost-assessment. I explain that
while I might make recommendations in my report, I’m not responsible for acting
Less-Than-Ideal and Proactive Ergonomic Solutions 19

on them and cannot guarantee when or even whether they would be implemented. I
encourage them to check in with their employer about the progress of implementing
any ‘­further recommendations’ in a timely manner. Different organisations have dif-
ferent approval processes, ordering, and supply of recommended equipment, so the
lead time for implementing change varies greatly.
Implementing as many temporary measures as possible to support the client
physically within their workstation s­et-up is also successful to facilitate enduring
­workstation-use changes. This gives the client the opportunity to try various mea-
sures to see which suits them best, allowing them to be actively involved in the design
process and provide feedback. It also leaves them with the support in place rather
than waiting for a deferred strategy. In this case, had I provided a temporary footrest
to facilitate the development of new postural habits and paid closer attention to his
keyboard and lowered the tabs, the client may have experienced a reduction in symp-
toms quickly ­post-assessment.
After 25 years as a health professional, I am still constantly learning. That’s
one of the things, along with the thrill of helping clients feel and function at their
best, which inspires me and brings me great satisfaction. Reflecting on this ‘­failure’
prompted me to make essential changes to my approach, my assessment, and the
systems of communication and f­ ollow-up that I use that have enhanced the outcomes
for my clients since.

FROM GOOD TO ALMOST IDEAL

A few years ago, I came across the most creative alteration of a workstation made by
an employee that I had ever seen. I am compelled to share this story because helping
this employee navigate a safer and more successful outcome was challenging but
also a lot of fun! When I entered this office environment, it was because I had been
engaged to conduct individual ergonomic assessments for employees who opted in.
Some of the staff were giggling and were in good humour. ‘­Wait until you see Jay’s
desk!’,2 they laughed and pointed to her workstation where she was standing with a
big grin on her face. It appeared that she had modified her ­ill-fitting standing station
with various boxes (­­Figure 2.1) so that it looked more like a ‘­tower of terror’ to an
ergonomist (­­Figure 2.2), but I grinned back and walked over to start our assessment.

From Good to Better

Jay explained that her low back and anterior hips became very sore during her
­one-hour daily commute to work via car. By the time she arrived at work, sitting down
for administrative work was extremely uncomfortable. Hence, she had requested a
standing desk and had been provided one since. Unfortunately, the desktop stand-
ing station that was provided approximately six months prior to my visit was not
­height-adjustable, nor did the mechanism work to lower down to the sitting position.
She had no chair assigned to her workstation and confessed that she did not sit down,
except in the lunchroom during breaks. Standing all day did take its toll: She felt tight

2 A fictional name has been used to protect client confidentiality

20 Ergonomic Insights

F­ IGURE 2.1 Approach view of Jay’s fixed standing workstation before the ergonomic
assessment.

in her legs and lower back in the afternoons. Yet, sitting had been more uncomfort-
able, so she just ‘­put up with it’. Thankfully, her work environment and role allowed
her to move around often. Yet, she was often standing still at her desk for prolonged
periods of up to two hours throughout her workday.
Assessing Jay within her workstation showed that the height of the keyboard tray
was far too low. She had subsequently placed the keyboard on the top section of the
‘­standing desk’ and propped one end on a box to make room (­­Figure 2.3). It was
turned towards the right, rather than centrally between screens. Her mouse was also
squeezed onto the box beside the keyboard, on a mouse pad that hung off the edges.
Moreover, her screens were grossly uneven in height. The laptop was placed on the
desk, so it was quite low and the monitor at its maximum height. This monitor height
was appropriate but its positioning to the right of the desk resulted in an awkward
standing posture, twisted to the right. On questioning, Jay answered that she used the
dual screens equally. Therefore, we suddenly became aware of the repetitive neck
Less-Than-Ideal and Proactive Ergonomic Solutions 21

­FIGURE 2.2 Side view of Jay’s standing workstation before the ergonomic assessment.

flexion/­extension and rotation, coupled with trunk rotation that had been occurring
during her computer and keyboard use.
The desk was also extremely cluttered, under, on top, and around the standing
desk (­­Figure 2.1). We cleared some items away and found a chair for her so that
we could assess her seated work approaches and determine how we could create a
comfortable option for her. I explained some disadvantages of standing at her desk
for prolonged periods, which included those that she had experienced, such as tight
calves and lower back. She agreed that being able to sit down at her desk for periods
throughout the day would be ideal if she could feel comfortable.
An assessment of the available seat showed that the seat pan in this chair was not
deep enough for Jay, meaning that the distal part of her thighs was unsupported. To
compensate, she tended to alternate between tucking her legs under her chair, sit-
ting on one leg crossed under the other thigh, or perching on the front of the seat.
22 Ergonomic Insights

­FIGURE 2.3 Front view of Jay’s fixed standing workstation before the ergonomic assessment.

Furthermore, neither the height nor lumbar support was adjustable in the backrest.
Yet, it reclined sufficiently and could be locked or unlocked to allow movement.
I talked her through some posture tips that could help her comfort while sitting.
These included sitting her ‘­butt bones’ back in the seat to avoid posterior pelvic tilt
for prolonged periods, which can increase loading on spinal, shoulder, hip, and pelvic
complexes, and resting her back on the backrest to reduce muscle strain. This also
gave her more support for her thighs and reduced hip overactivity, which can lead to
strain of the low back, pelvis, and hips. We also cleared an area on the desk beside
her standing station so that she could sit down throughout the day. We discussed her
need for a new chair and a ­sit-stand workstation but, in the meantime, moving her
laptop, keyboard, and mouse down onto the desk would provide her with a sitting
option that felt comfortable for short periods.
At the time of the assessment, by using reams of paper, we were able to raise and
centralise the keyboard, and we broadened the ­mouse-use area. A different box of
appropriate height was used to raise the laptop screens, and both were moved closer
together to facilitate ease of use between them with reduced neck and trunk move-
ment. While these were temporary and ungainly looking measures, they provided a
comfortable interim measure.
Moreover, I demonstrated a variety of standing postures that Jay could position
herself in to change her weight distribution and relieve the load on her body while
standing. We also practised a variety of stretches and exercises to improve her flex-
ibility and endurance in standing. Importantly, we practised stretches and exercises
in the sitting position that helped improve mobility of her hips, low back, and trunk,
with others to strengthen her core stability. Sprinkling these into her workday, along
Less-Than-Ideal and Proactive Ergonomic Solutions 23

with frequent posture adjustments and a more ‘­ergonomically friendly’ workstation,

would likely help to improve her work capacity and comfort during sitting.
I highlighted Jay’s situation as ‘­high risk’ because she was suffering considerable
symptoms daily. While the People and Culture team had been aware of the multiple
modifications that Jay had needed to make to alter her desk to be ‘­­semi-usable’, no
one had really thought about the health and safety risks. In their attempt to address
her complaint about painful sitting, they had provided a l­ow-cost desk that was com-
pletely unsuitable. They had not consulted with an ergonomic or health professional
in advance to ensure that the best solution was reached.
As it is often the case, based on my experience, the People and Culture man-
agement team were likely conflicted between s­ hort-term cost savings and l­ong-term
return on investment, because budget constraints were repeatedly mentioned. It is
also interesting how this employee adopted an ‘­I’ll make the best of it’ situation and
was unaware of the risks for her health in accepting such a compromise. This is the
flipside of psychological risk factor assessment, where an individual’s positive dis-
position and tendency to avoid ‘­a fuss at work’ increased the worker’s risk of injury.
I talked Jay through how she might be able to adapt the principles of Alan Hedge’s
ideal work pattern of s­ itting-­standing-stretching3 to suit her physical needs and work-
flow. Jay believed that sitting for 20 minutes, standing for eight minutes, and stretch-
ing or moving for two minutes might not allow her to focus on ‘­deep work’ for long
enough periods. Nonetheless, she agreed to try standing less of the time than she had
been, sitting for more time than she had been, moving more frequently between posi-
tions, and incorporating stretches and exercises in between. This all hinged upon her
receiving the new s­ it-stand workstation and chair.
I also discussed with Jay her sitting position in her car seat and talked about some
ergonomic, movement, and posture principles that she could apply when adjusting
her car seat to reduce strain on her hips and low back while driving. She thought that
bringing the seat closer might be pertinent to reduce hip flexor overactivity and leg
extension while improving lumbopelvic positioning. We also practised small lumbo-
pelvic and trunk movements that she could easily do while driving and sitting at her
desk to reduce stiffness and soreness.

From Better to Almost Ideal

A new chair with a deeper or d­ epth-adjustable seat pan was necessary to facilitate
comfortable sitting. The People and Culture team, myself, and Jay agreed on a plan
that included ordering a desktop, fully h­ eight-adjustable ­stand-capable workstation,
preferably an electric one with a memory function that would enable Jay to easily
and frequently move between sitting and standing positions. Before leaving the office
that day, I spoke with the People and Culture Manager about a plan to f­ ast-track the
ordering of her equipment. Their usual process for gaining approval of a request
for a ­stand-capable desk was typically a letter from the employee’s treating doctor
or therapist. This had, however, failed to result in the prescription of appropriate
­stand-capable desks for other employees also.

3 https://­ergo.human.cornell.edu/­CUESitStand.html
24 Ergonomic Insights

Thankfully, the employers agreed to order the chair and electric s­ it-stand desktop
workstation that I recommended as soon as possible. Had they been hesitant to do so,
it would have been an occasion where I would have felt it necessary to subtly point
out their legal obligation to provide a safe and healthy work environment. On many
occasions, I have seen employers, or their People and Culture team, fail to consider
or facilitate the ‘­fit’ of an employee with their work and work environment to ensure
that they can work safely and effectively, as is outlined in legislation (­WHS Act,
2012).
At the f­ ollow-up three weeks later, the desk and chair were in situ for this client.
Jay was experiencing significantly reduced symptoms in her back and hips, and she
found that working between sitting and standing was a comfortable strategy. Her
commute was also easier, and she was arriving at work and home at the end of the
day less stiff and more refreshed. I encouraged her to communicate any ongoing
questions or concerns with her manager or me.

Proactiveness Pays Off

Since this assessment, I have endeavoured to encourage organisations to develop sys-
tems for employees and employers to communicate more effectively and efficiently
regarding potential health risks. This can be, of course, a delicate topic that requires
a careful approach, because no organisation wants to feel accused of being negligent
in its communication methods. I believe that it is up to both parties, the employee and
employer, to foster a ‘­culture of care’ that allows employees to voice their health con-
cerns without fear. It is also the responsibility of the employer to approach employees
when they are concerned about their health and safety and work towards solutions in
a timely manner.
In this instance, it became evident that the People and Culture management team
were aware of the inadequacy of Jay’s standing workstation but accepted that she was
‘­okay with making do’. They failed to see the health and safety risks or the urgency to
engage a specialist consultant. Thankfully, this annual ‘­office sweep’ of ergonomic
reviews brought Jay’s needs to light and addressed them before her situation wors-
ened. Other employees were also suffering from ­ill-fitting ­sit-stand workstations so
the need for more individualised assessment and prescription of these by a trained
ergonomist was suggested to management for their future consideration.
Many inappropriate ­stand-capable desks had to be disposed of. That was a waste
of company resources that could have been avoided by the prescription of bet-
ter products. It is difficult for untrained people to assess the appropriateness of a
­sit-stand desk because most information online is distributed by potentially biased
parties with commercial interests whose priority is to sell their products. In addi-
tion, governmental and educational bodies’ policies typically mention taking heed
of a referral for a s­ it-stand desk from a ‘­medical professional’ in the case of injury or
medical condition.4
Many medical professionals, however, have no training in ergonomics and can
be unaware of the nuances in ­sit-stand desk prescription. Several factors should be

4 https://­www.safety.uwa.edu.au/ ­­health-wellbeing/­physical/­ergonomics/­workstation/­­sit-­stand-desks
Less-Than-Ideal and Proactive Ergonomic Solutions 25

assessed, such as the ‘­fit’ of a s­ it-stand desk for the frame of the client, their tasks
and workflow, the dimensions of the workspace, and the other equipment they use.
The time lost to poor health and productivity because of delayed intervention, plus
the cost of purchasing inappropriate furniture, typically far outweighs the cost of
engaging an ergonomist.
In this instance, no employees of this company had lodged a claim through
‘­Return to Work SA’ relating to the pain and stiffness that they reportedly experi-
enced throughout their workday at their desks. Many were seeking physiotherapy
treatment at their own expense. Yet, this ergonomic assessment and intervention was
undoubtedly timely to avoid further aggravation and cost for both this employee and
employer. I constantly try to encourage employees and employers to maintain an
open yet respectful dialogue about their comfort and satisfaction with their work
environment. When both parties demonstrate care and concern for each other’s
needs, employee engagement, productivity, and satisfaction are greatly increased
(­Mani & Nadu, 2011).
Healthy ergonomics creates a ­win-win situation for everyone!

REFERENCES
Lerner, D., & Henke, R. M. (­2008). What does research tell us about depression, job perfor-
mance, and work productivity? Journal of Occupational and Environmental Medicine,
50(­4):401–10. DOI: 10.1097/­JOM.0b013e31816bae50.
Mani, V., & Nadu, T. (­2011). Analysis of employee engagement and its predictors. International
Journal of Human Resource Studies, 1(­2):15–26. DOI: 10.5296/­ijhrs.v1i2.955.
WHO. (­2000). Mental Health and Work: Impact, issues and good practices, World Health
Organisatation, Geneva. https://­apps.who.int/­iris/­bitstream/­handle/­10665/­42346/­WHO_
MSD_MPS_00.2.pdf
Work Health and Safety Act 2012. (­South Australia). V.3.10.2019 (­Austl.). Retrieved from
https://­w ww.legislation.sa.gov.au/­_ _legislation/ ­l z/­c /­a /­work%20health%20and%20
safety%20act%202012/­current/­2012.40.auth.pdf
 3 ­ eturn-­to-Work and 24/­7
R
Warehouse Operations
Wenqi Han

CONTENTS
Ergonomic Intervention for an Office Worker with Spinal Cord Injury................... 27
Ergonomic Assessment for 24/­7 Warehouse Operations.......................................... 32
References................................................................................................................. 37

ERGONOMIC INTERVENTION FOR AN OFFICE

WORKER WITH SPINAL CORD INJURY
Disability includes several aspects, such as cognitive, developmental, intellectual,
mental, physical, and sensory deficits, and any mixture of these that affect function.
Disabilities affect personal lifestyles and can be genetic or befall a person during
their life journey. In Singapore, people with sensory and physical disabilities con-
stitute about half of the disability group, with the remainder including intellectual
disabilities and autistic spectrum disorders.1 Also, worker disabilities can be classi-
fied to differentiate and facilitate employment matching with their job specifications.
This is done when assessing the medical condition through sensory examination,
motor examination, and determination of single neurological level, complete or par-
tial spinal cord injury (­SCI), and grading of impairment.2
This case is about my experience in conducting an ergonomics study and develop-
ing a ­return-­to-work programme for a previously fit male weighing 75 kg and 170 cm
stature with no underlying medical conditions. Due to privacy and confidentiality
reasons, he will be referred to under the alias “­James”. James was a ­30-­year-old con-
struction planning engineer. In 2017, he was involved in a ­hit-­and-run collision while
crossing the road during his commute to work one morning. James suffered a spinal
shock and was diagnosed with Asia Impairment Scale (­ASIA), Grade C, T12 of the
thoracic spinal segment, a SCI. He required wheelchair assistance and was admit-
ted to a rehabilitation unit in the hospital. After two weeks of hospitalisation, James
underwent weekly physiotherapy.
As a Workplace Safety and Health (­WSH) consultant, I was approached by the
Human Resource Manager and Operations Director to attend an informal meeting.
They wanted me to perform an ergonomic study and suggest measures about the
­return-­to-work programme of our injured colleague. Since James was on a ­90-day

1 https://­www.msf.gov.sg/­­media-room/­Pages/­­Total-­number-­of-­persons-­with-­disabilities-­in-Singapore.aspx
2 https://­www.spinalinjury101.org/­details/­­levels-­of-injury

DOI: 10.1201/9781003349976-3 27
28 Ergonomic Insights

medical leave, this was the implied deadline to craft a plan to implement workplace
adjustments. People with SCI face significant environmental barriers that affect their
social participation and employment (­Tsai et al., 2017). In general, an ergonomic
assessment should be conducted to assess the worker rehabilitation needs by consid-
ering the medical diagnosis, task requirements, and workstation layout.
I considered the medical diagnosis of James to gain a basic understanding of his
needs. People with ­T1–T12 paraplegia have nerve sensation and function of all their
upper extremities. They can transfer independently and manage bladder and bowel
function. Individuals with a ­T10–T12 injury have better torso control than those with
a ­T2–T9 injury, and they may be able to walk short distances with the aid of a walker
or crutches.2
During my research and reading, I considered two options taught during my uni-
versity studies: the ASIA International Standards for Neurological Classification of
Spinal Cord Injury checklist,3 where the sensory and motor functions are scored,
and Spinal Cord Injury Research Evidence (­SCIRE) Outcome Measures Toolkit.4
The utilisation of both tools was agreed upon after consultation with the company
doctor, who had also assisted me in conducting a clinical neurological examination
on James to rate his sensation and muscle function during his medical leave. The
doctor informed me that James would still need the assistance of a wheelchair after
his 9­ 0-day medical leave and ­return-­to-work.
I conducted an ergonomic investigation on James’s desk to evaluate compliance
with the Singapore Standard SS514:2016 Code of Practice for Office Ergonomics
(­Singapore Standards Council, 2016). This is a mandatory requirement that governs
office ergonomics in the Singapore context. This assessment was essential to dis-
cover opportunities to redesign the workplace. As part of the investigation, I took
pictures and measured the existing desk dimensions (­L: 1,200 mm × W: 600 mm × H:
750 mm) and the room’s layout (­L: 6,100 mm × W: 3,600 mm). Also, I called James
on the phone to understand his substantive and routine work activities before decid-
ing whether a workplace redesign was needed. His regular work activity included
using a computer for typing reports (­6 hours/­day) and walkabouts to collaborate with
others or obtain updates and progress details (­­2–3 hours/­day).
I compiled the data and information needed to inform my recommendations:
wheelchair dimensions and functions based on online research and informa-
tion from the company doctor, and a review of James’s previous work area, per
the Accessibility Code 2019 by the Building Construction Authority of Singapore
(­Building Construction Authority, 2019). After contemplating the human, logistical,
and infrastructure parameters, I synthesised the information and prepared a proposal
for managerial approval. The proposal included a ­to-do list and a breakdown of the
critical considerations for redesigning the workspace to accommodate James. During
the ­co-design process, I also consulted with James. His only concern was the move-
ment and manoeuvring of his wheelchair within the workplace.

3 https://­www.­physio-pedia.com/­American_Spinal_Cord_Injury_Association_(­ASIA)­_Impairment_Scale
4 https://­www.­physio-pedia.com/­Spinal_Cord_Injury_Outcome_Measures_Overview
Return-to-Work and 24/7 Warehouse Operations 29

­TABLE 3.1
Principal Changes in James’s Work Design
Previous Work
Activity Revised Work Activity Duration Changes Main Workplace Changes
Use of computer for Unchanged Reduced from 6 to Redesign of workspace
typing reports 5 hours and desk to help James fit
into the environment
Walkabouts to Use of computer system to Unchanged Use CCTV instead of site
collaborate, obtain monitor worksite progress (­­2–3 hours) walkabouts to monitor
updates and through artificial progress and receive
progress details, intelligence updates
etc.

The proposal was compiled based on no changes in job functions and scope
of work, meaning a return to his substantive duties in full, and resulted in the
­equipment-related work design changes (­­Table 3.1).
Pertinent to the workplace redesign, I considered the (­1) stationary dimensions of an
adult wheelchair, (­2) manoeuvring dimensions of an adult wheelchair, (­3) dimensions
of the office layout, (­4) dimensions of the common access corridor, (­5) dimensions of
adult wheel chair side reach, (­6) dimensions of adult wheelchair front reach, and (­7)
Smart Commodity CCTV (­mounted on tower crane mast and every storey) for the iden-
tification and ­real-time monitoring of work area (­360°). The final proposal included (­1)
power socket ­outlet – height at 900 mm, (­2) ­wall-mounted adjustable monitor screen at
1,200 mm (­360°), (­3) ­two-way lighting s­ witch – height at 900 mm, (­3) ­air-conditioning
remote ­control – height at 900 mm, (­4) emergency press ­button – height at 900 mm
(­linked to the reception desk with sound alarm and SMS alert), and (­5) ­wall-mounted
adjustable work desk of height: 850 mm, depth: 600 mm, and length: 1,200 mm.
The management approved the proposal. As the changes and investments required
for the redesign were not major, the management started the procurement process
within two days while enquiring about possible government grants to defray the
costs. The minor renovation took two weeks to complete with a cost of $13,500,
which, in addition to the design features presented above, included:

• Installation of a wardrobe (­height: 900 mm, width: 300 mm, and length:
3,600 mm),
• Alteration to partition wall to install conceal conduits for lighting switch
and power socket outlets,
• Electrical wiring works,
• Data and CCTV cabling works, and
• Installation of an adjustable bracket for the desktop screen.

Interestingly, managers felt that they should invest in technology to aid everyone, not
only James, in the era of technological advancements. They realised that installing
30 Ergonomic Insights

the CCTV to view updates instead of performing site walkabouts would be a risk
reduction method to minimise exposure to various hazards in physical worksites
for other employees. Physical walkthroughs can hide risks like slips, trips, and falls
(­STPs), which could be eliminated by minimising the exposure to the hazards by
deploying an intelligent CCTV for meetings and discussions through ­real-time con-
nections to the worksite. This could positively affect safety, productivity, and effi-
ciency, and the adoption of smart innovations and technologies to ease task load
could be perceived as beneficial by the workforce. Of course, someone must still
balance remote work with ­on-site physical presence to engage with employees, build
trust, and empower a psychologically safe work environment. Equally important,
the opportunities to attend worksites and not just monitor them from a distance
should be given to workers to avoid long sedentary activities and promote physical
fitness.
The management proceeded with this initiative, but the CCTV vendor reminded
us about the option for personnel to work from home and access an online platform to
­co-utilise the CCTV with Internet access and password upon management approval.
An option was offered for an ­add-on to the bundle on Apple’s Siri, a virtual assistant
in Apple Inc.’s operating systems. Nonetheless, those two features were not installed
due to considerations about the feelings of James. We intended for workplace inclu-
sion and protecting the dignity of the recovering colleague. Working from home
could be promoted when the information technology, Internet connection, and organ-
isation’s system accessibility are enabled. This could encourage flexible work too.
I felt a sense of achievement after the renovation was completed. I reflected on the
experiences and challenges that this project presented: the initial meeting with the
Human Resource Manager and Operations Director, the concerns about the worker,
the need for an objective and ­scientific-based approach, the conduction of the ergo-
nomic investigation, and the completion of the workplace redesign. The insights that
I gained were valuable. I did not have prior experience in handling r­eturn-­to-work
programmes and performing ergonomic investigations of workspaces. Thus, it was
challenging to gather all necessary information in a limited time and prepare the
proposal.
I had thoughts of inviting an industrial ergonomist to provide professional advice,
but time constraints did not allow for that. Also, this could be partly attributed to
my own exploratory personality with perseverance to confront new challenges and
a “­willing to do” attitude to complete the proposal. After all, I was employed based
on my basic knowledge of ergonomics as part of my bachelor’s degree in safety,
health, and environmental management. I was trained and assessed in this course to
demonstrate competency in carrying out ergonomic assessments by using the tools
I applied to this case. Furthermore, it is not a stipulated requirement to engage an
industrial ergonomist for such evaluation and planning. Nevertheless, time and finan-
cial constraints are areas of concern, meaning that the involvement of an industrial
ergonomist may not always be feasible. Indeed, it would be worth examining when
and how to mandate the engagement of ergonomists in specific cases and possibly
recruit industrial ergonomists to contribute to WHS and ­well-being aspects.
­Return-­to-work is a humane approach, an obligation, and a duty of care for
employees. Workplace adjustments are individualised solutions that enable persons
Return-to-Work and 24/7 Warehouse Operations 31

with disabilities (­PWD) to carry out tasks and remain productive. Adapting the
work environment, providing assistive devices, modifying working schedules, and
redistributing ­non-essential tasks to other workers are some examples of reason-
able accommodations. Implementing those is a vital path for increasing employment
for PWD who often encounter difficulties with functional movement or exertion
demands related to routine work.
In general, a thorough assessment supported by management can realise work
redesign that considers PWD and provides an inclusive workplace that offers more
agility for others once the learnings are learned. In this case, the implementation
of CCTV technology led to efficiencies and risk reduction for all team members
involved. It is conceivable that workplace adjustments to cater for the needs of PWD
during their r­eturn-­to-work could challenge employers if they are ­ ill-prepared.
Unfortunately, some organisations might underestimate the value of r­ eturn-­to-work
schemes and miss the opportunity for workplace inclusion of injured employees.
Maybe, in such organisations, there is a perception that injuries are temporary, and
healing shall happen only at home or elsewhere (­e.g. sheltered workshops).
However, a more proactive approach is warranted as PWD represent a signifi-
cant percentage of the population and can be imaginative people with skill sets
that should be recruited and retained in a workforce. For example, building designs
shall incorporate accessibility to the workplace and other facilities (­e.g. car parks,
ramps, lifts, and washrooms). Furthermore, apart from PWD, with a retirement age
stipulated at 67, an increasing worker population group clearly requires ergonomic
considerations for an accessible workplace. With a f­ast-ageing population, we need
interventions initiated by any level of stakeholder and a coordinated response among
government authorities, company ­decision-makers, renovation contractors, Human
Resource managers, industrial ergonomists, and WHS professionals.
In Singapore, for individuals over 50 years old, around 13.3% are considered dis-
abled; between ages 18 and 49, about 3.4% are disabled; and 2.1% of children under
18 are disabled in Singapore. Of those with a disability, around half are considered
physical or sensory disabilities. One in 68 children in Singapore has been diagnosed
with autism, and this number has increased over time. About 5 to 6% of children
born in Singapore have developmental problems of various types, and 0.55% of the
Singapore workforce has a disability of some kind.1
From a s­elf-reflection viewpoint on this ergonomic intervention project for an
office worker with SCI, I would like to share my thoughts and critical insights gained:

• I am someone with high expectations, and I feel there is an immediate need

to pursue further education, focusing on human anthropometry, h­ uman–
machine interface, and ergonomics of tool design to enhance my knowledge
to equip myself for more uphill challenges.
• On top of the physical ergonomics, we also need to have the skill sets to
understand cognitive ergonomics, mental health, and ­well-being of persons
returning to work.
• The psychosocial risks arising from constraints imposed by organisational
safety climate and culture, perceptions of individuals, and diverse human
factors characteristics can significantly differ across space and time.
32 Ergonomic Insights

Based on the above, I am currently exploring a career development plan through

continuing education. Another option I consider is ­self-study of related research and
books to enrich my knowledge base. I believe that honing my skill sets is similar to
sharpening the saw. This is also one of the habits of successful people indicated by
Steven Covey in his ­book – 7 Habits of Highly Effective People (­Covey, 2009).

ERGONOMIC ASSESSMENT FOR 24/­7 WAREHOUSE OPERATIONS

In this case, I worked as a WHS manager in a logistics and warehousing company.
The past injuries and incidents in the logistics and warehousing industry supported
the need to implement effective plans to mitigate risks and improve the ­well-being of
employees. Pickers are exposed to the risk of collision with forklift trucks. Accidents
involving forklifts and trucks are rising in the logistic and warehousing environment
(­Lam, 2017; Min, 2017).
This organisation had a headcount of 1,795 workers, 1,200 of which were driv-
ers, 55 workshop mechanics, 150 administrative staff, 25 management personnel, 15
salespersons, and 350 warehouse staff. On my first day at work, after my orientation
and introduction to the organisation, I browsed through the files at my work desk left
by my predecessor. I found documents about risk assessment and safe work proce-
dures for forklift operations. I asked my colleagues sitting nearby, two with manage-
ment roles and one warehouse staff, about their perception of WHS at the company.
Essentially, they replied, “­just do the bare minimum; if there is no need to change,
the better”. I also noted that there was no established WHS management system, like
policies, procedures, training materials, and reporting methods.
On my second day at work, I asked the warehouse manager about WHS in his
area of responsibility. He explained that the authorities only required a risk assess-
ment and safe work procedure, audited once every three years. Other than that, the
manager stated, they did not need to do or have more, and everyone knew that safety
was paramount. When I asked about the incident rates, he replied, “­touchwood, we
had eight minor injuries last week, which we consider normal”. I informed the ware-
house manager that I would propose a WHS action plan for him and the management
to consider. The meeting ended with him advising me, “­Don’t do too much to hinder
the work progress, and don’t stop any work unnecessarily”.
Two days later, at about 09:15 am, my phone rang. It was the warehouse manager.
“­Morning Han”, he said, “­are you available to attend a short meeting at the 2nd storey
meeting room at 10:00 am regarding the recent direction by the management on the
24/­7 warehouse operations?”. After the call ended, I tried to brainstorm what they
might need from me. I thought that I should have some information handy about the
risk profile of the workforce based on their job types. I scribbled on my notebook
the immediate thoughts that emerged from my academic studies on ergonomics and
related, especially, to sedentary and ­non-sedentary job activities.
Additional thoughts included information about the employees’ lifestyle (­e.g. eat-
ing habits, weight management, and tobacco use), which I jotted down. Sleep was
the next concern because I wondered whether prolonged sleep deprivation or sleep
pattern changes and their possible impacts could be an issue for the workforce. This
preparation took me about 40 minutes, including data collection and searching for
Return-to-Work and 24/7 Warehouse Operations 33

an appropriate survey tool. I found that operations in the warehouse typically ended
at about 22:00 each day, after significant overtime. Presumably, this could have trig-
gered management to consider a ­12-hour shift and 24/­7 operations. I also found the
Basic Health Survey Checklist developed jointly by the Workplace Safety and Health
Council and Ministry of Manpower of Singapore (­WHSC, 2018).
I quickly proceeded from my work desk to the meeting room. I did not want to
be late. The meeting started with topics about workforce, work pass issues, accom-
modation, food, insurance, payroll, utility bills, upcoming contract for orders, need
to ramp up outgoing cargos of extra 50%, and expected revenue of 25%. I waited
for my turn, which I saw on the projector screen with “­Health & Safety for 24/­7
Warehouse Operations” with no content. I asked the warehouse manager, “­Can you
clarify what is expected of me as a WHS professional to contribute to this topic?”
There was complete silence in the meeting room for a few minutes while colleagues
looked at each other.
Following those awkward silent moments, I shared all the key concerns from
a risk management point of view based on my earlier brainstorming and cursory
research. I explained that I could design a checklist to gather data from individuals
with assistance from the Human Resource Manager, company doctor, and line super-
visors. Then, I would compile and submit an Ergonomics Risk Management report.
The points and recommendations I shared were recorded in the meeting minutes.
After lunch that day, I returned to my work desk, turned on the power of my
desktop, and started typing a draft proposal with the key points that I had written in
my notebook earlier in the morning. To gather data and understand the profile of the
workforce, I built a survey form with questions about demographics and individual
characteristics (­e.g. age, gender, weight, height, (­non)­sedentary job tasks, eating,
sleeping and smoking habits, mental health, and recent/­current medical conditions),
effects of the work system (­e.g. fatigue, work pace, postures, stress), awareness about
accidents and WSH, and environmental factors (­e.g. temperature, humidity, lighting,
ventilation, noise, vibrations). The Basic Health Survey Checklist mentioned above
was rather generic. Therefore, I thought of enriching and adjusting it to accommo-
date more contextualised items applicable to the warehouse environment. There was
no time, and nobody with the necessary knowledge was immediately available to
review the draft checklist.
The survey form was emailed to the Human Resource Manager, and it was printed
and distributed to everyone through the line supervisors and heads of departments.
The entire workforce participated in the survey at a designated workstation with dif-
ferent time slots and a short briefing on the instructions and rationale of this survey.
The process was also assisted by three interpreters of the native languages, namely
Malay, Mandarin, and Tamil. As Human Resource is being perceived as a depart-
ment with authority and representing the directions of top management, the 100%
response rate was somewhat expected.
The responses took about four days to come back to me, and data compilation took
another two days. Nonetheless, I felt that the psychological safety within the work-
place to express and accept factual feedback was at a low level. Therefore, the reli-
ability of the data collected could have been compromised due to fears of a backlash.
Hence, I carried out a walkthrough at the warehouse to evaluate the environmental
34 Ergonomic Insights

factors for verification purposes. The ­20-­year-old facility was ­run-down and not
­well-maintained, and humidity and temperature in the warehouse were a concern.
Most of the lighting was coated by dust. Ventilation was poor, and the environment
was also dusty due to the poor housekeeping and regular traffic of vehicles. The
engine noise from transportation vehicles was also a factor, as prolonged exposure
could cause hearing problems.
The information was recorded and used in my risk assessment. As a WHS practi-
tioner, in the light of these observations, I asked myself, “­how did such an organisa-
tion exist? And for such a long time?” I felt that improving the work environment
could be a new challenge that I would like to conquer by gaining ­buy-in from the
­decision-makers and stakeholders. There was another thought which came across my
mind. During a job interview, how about everyone seek permission from the inter-
viewers to have a short tour around the operations area to catch a glimpse of what
kind of workplace they are going to work in?
The survey results revealed that 60% of the workforce were locals, aged above
45 years old, and 40% were foreigners, between 20 and 30 years old. Below, I list
the main findings from the survey and some data I distilled from annual medical
­check-ups performed by the company doctor. I have made indicative notes about
their importance:

• 18% of the employees performed sedentary work without regular breaks for
physical activities. Those workers could be exposed to a higher possibility
of heart diseases, diabetes, obesity, high blood pressure, stroke, depression,
and chronic cancer due to physical inactivity.5
• 75% of the workforce fell under the obese category, and 70% of the work-
force had high blood pressure and did not often exercise due to their long
working hours and overtime. Obesity combined with environmental stress-
ors leads to several chronic illnesses. Poor eating habits may range from
irregular hours of eating to disproportionate amounts of food intake, includ-
ing habits like eating dinner late.5
• The travelling time between work and home through shift work took more
than 65% of workers’ day, on average 16 hours. Notably, the warehouse was
very far from the nearest public eatery facility, which is 2 km away. Shift
work deprived employees of exercising options as they needed additional
rest after the long working hours. Several gastrointestinal (­GI) disorders
such as ulcers are more common across shift workers than other employee
groups. Also, shift workers are more likely to suffer abdominal pain, gas,
diarrhoea, constipation, and nausea caused by a decrease in appetite and
indigestion.6
• 85% of the employees were smokers. Tobacco consumption leads to heart
diseases, high blood pressure, stroke, and other chronic cancers. Smokers
suffer from respiratory diseases, severe airway damage, emphysema, and
chronic bronchitis.5

5 https://­medlineplus.gov/­healthrisksofaninactivelifestyle.html
6 https://­www.medicalnewstoday.com/­a rticles/­list-of-digestive-disorders#types
Return-to-Work and 24/7 Warehouse Operations 35

• 75% of the workforce felt overloaded with tasks and stressed by manage-
ment’s high demands and expectations. Although small amounts of stress
can be reasonable and motivate performance, chronic stress can lead to
serious health problems. Multiple daily challenges (­e.g. ­fast-paced envi-
ronment, meeting deadlines) together with other internal and external
environmental stressors (­e.g. noisy work environment, poor workplace
lighting, family commitments, personal matters) can lead to excessive and
prolonged stress.
• 85% of the workforce complained about inadequate rest as they are required
to work overtime till 10:00 pm on most of the days. As restoration and
renewal of the human body occur during sleep, victims of sleep deprivation
often suffer from physical and emotional disturbances (­Medic et al., 2017).
Also, a disruption of circadian rhythms, which regulate the “­normal” awake
and sleep cycles, can make people sleepy, somnolent, or unable to sleep
when possible.5

I started drafting my proposal to suggest how to eliminate or reduce for all employ-
ees the WHS risks and promote health through workplace interventions. I proposed
solutions by consulting the company doctor, based on my previous experiences and
ideas from the literature (­­Table 3.2). As there were time constraints and this was the
first WHS assessment in this organisation, I did not consult with the workers.
I submitted my proposal, and the managers jointly decided to proceed with the
24/­7 operations of the warehouse. However, they also decided to shelve my proposal
due to their perception of high implementation costs. They reiterated that having a
risk assessment and safe work procedure was good enough. Implementing the rec-
ommended risk control measures was not perceived as necessary because they would
not be required to demonstrate compliance with the authority at their next visit.
My reflection on this failure to gain the ­buy-in of my WHS improvement proposal
generated mixed feelings. I wondered, who should be responsible for WHS? Why did
they reduce WHS to just documentation of a risk assessment and safe work proce-
dures? What was the role of the auditors? Had they performed physical inspections?
Had they interviewed any workers? How could the company have passed the audit
with so many issues? Through my reflection, I realised we should assess an organisa-
tion’s readiness for change by understanding management commitment, resource and
support allocated, and existing barriers that workers face. Last but not least, the per-
ceptions of all stakeholders that affect the organisation’s psychosocial safety climate
and culture will drive the intent and commitment to invest in the safety, health, and
­well-being of the workforce.
When no mishap occurs, the definition of “­reasonably practicable” measures is
not questioned. Promoting greater ownership to encourage voluntary efforts is good
for proactive safety but can be perceived as unproductive from an o­ utcome-based or
purely productivity perspective. Many other questions emerged! Where is the lead-
ership, and what is their commitment to ensuring WHS? Will they be ever ready to
integrate WHS into work processes? Why did the previous WHS incumbent leave?
What should I have done differently to gain b­ uy-in from management on my pro-
posal? How would they handle civil litigation claims if any employee suffers illness
36 Ergonomic Insights

­TABLE 3.2
Workplace Risks and Strategies
Risks Strategies (­and Indicative Sources Where Applicable)
Poor health due to Alarm reminder every 2 hours to remind administration office staff to do stretching
sedentary job Workspace redesign for both healthy staff and people with disabilities
tasks. Internal gym facilities
Internal clinic facilities
Quarterly body ­check-up regime
Consider “­Keeping fit”/­Align Body Mass Index (­BMI) as one of the key
performance indicators (­KPIs)
Assessment to understand current office work conditions and create a sustainable
work environment for administration staff.
Some of the suggested assessment tools were the Rapid Upper Limb Assessment
(­RULA), Rapid Entire Body Assessment (­REBA), and American Spinal Injury
Association (­ASIA).
Health impacts Wearable gadgets to monitor the health status
due to poor Staff cafeteria with “­healthy” meals provided for all staff free of charge
eating habits and Employment of dietician and nutritionist to create ­tailor-made menus together with
weight chef
management Displaying posters to encourage eating healthy and keeping fit
Regulate duration for meals (­e.g. lunch 11:­30–13:30 and dinner 17:­30–19:30)
Employees to take their meals before every work shift ends to ensure they do not eat
late after they go home
Poor health due to Smoking ­restrictions – restrict smoking corner in company premises
tobacco Smoking cessation clinic, hotline, and counselling
consumption Nicotine replacement therapy (­NRT) and antidepressants such as bupropion
Effects of stress Surveillance regime on medical leave rates
Quarterly cohesion events to knit bonding of colleagues, management, and present
appreciation awards
Annual holiday retreat trips
Medical benefit scheme for family members of employees
Counselling sessions
Disorders due to Company transport to and from the doorstep
inadequate sleep Company laundry services
Resting area for employees during short breaks
Annual sleep test regime
Use wearable gadgets to monitor employees’ blood pressure, heartbeats, etc.
Sleep intervention programme
Effects of adverse Regular luminaires level monitoring and maintenance of lighting
environmental Designated loading area with mechanical ventilation systems
factors Regular air particle monitoring and maintenance of ventilation systems
Vehicles to switch off their engine if idle for more than two minutes.
Noise monitoring
Hearing Conservation Programme and ensure all personnel are equipped with
hearing protectors
Hearing tests for all
Return-to-Work and 24/7 Warehouse Operations 37

due to a poor work environment and prolonged work hours? What are the business
continuity strategies and plans if the authorities uncover those unsafe working condi-
tions and breaches of employment law requirements?
My conclusion of this case is that a WHS management system or plan should be
embraced, supported, and effectively implemented. We are paid as an employee to
advise management on aspects of WHS legal compliance and control of all foresee-
able risks. However, the decision still lies in the managements’ hands. To the best of
our knowledge, we do what we can to recommend WHS initiatives and programmes
for implementation. However, the organisation’s cultural maturity journey might
be much slower than our expectations. Business continuity management and WHS
are critical elements to remain competitive in the market, but the latter might not
always be a priority. Leadership and commitment, training to build competencies,
and resources necessary to run a 24/­7 warehouse operation within a safe and healthy
working environment require investments that managers might not see necessary if
not enforced.
Looking back, I pondered if I were to restart again on this assessment for the
24/­7 operations of the warehouse, how could I do it differently? I may do it in a
more paced fashion by obtaining and processing currently available data from the
heads of departments instead of administering a new survey. An organisation with-
out data from past years to inform a trend analysis indicates few possibilities. First,
there might not have been much attention to WHS due to a lack of serious incidents.
Second, there could be poor competencies of internal WHS staff. Third, manage-
ment might be only interested in p­ rofit- and ­delivery-based outcomes. Thus, instead
of drafting a ­full-scale proposal, I could have suggested an improvement plan with
immediate actions to make the existing environment safer before setting sails for a
bigger mission.

REFERENCES
Building Construction Authority. (­2019). Code on Accessibility in the Built Environment
2019. Singapore: Building Construction Authority. Retrieved from https://­www.corenet.
gov.sg/­media/­2268627/­accessibility-code-2019.pdf
Covey, S. R. (­2009). The 7 Habits of Highly Effective People. New York: Rosetta Books
LLC. Retrieved from https://­f b2bookfree.com/­uploads/­files/­2020-05/­1590810411_the-
7-habits-of-highly-effective-people.pdf
Lam, L. (­2017). Logistics Firm Fined $80,000 Over Accident Where Forklift ran Over
Worker’s Legs. Singapore: The Straits Times. Retrieved from https://­ www.straits
times.com/­singapore/ ­logistics-firm-fined-80000-for-forklift-accident-that-ran-over-
workers-legs
Medic, G., Wille, M., & Hemels, M. E. (­2017). Short- and long-term health consequences of
sleep disruption. Nature and Science of Sleep, 9, 151–161. DOI: 10.2147/­NSS.S134864.
Min, C. H. (­2017). Lorry Driver Crushed After Forklift Drops Steel Bars in Fatal Industrial
Accident. Singapore: The Straits Times. Retrieved from https://­ www.straitstimes.
com/­singapore/­lorry-driver-crushed-after-forklift-drops-steel-bars-in-fatal-industrial-
accident
Singapore Standards Council. (­2016). SS 514:2016 Code of Practice for Office Ergonomics.
Singapore: Singapore Standard Council. Retrieved from https://­www.singaporestan-
dardseshop.sg/­Product/­SSPdtDetail/­b558a5ee-9bc3-4b0d-a96b-6e518a990f21
38 Ergonomic Insights

Tsai, I.-H., Graves, D. E., Chan, W., Darkoh, C., Lee, M.-S., & Pompeii, L. A. (­2017).
Environmental barriers and social participation in individuals with spinal cord injury.
Rehabilitation Psychology, 62(­1), 36–44. DOI: 10.1037/­rep0000117.
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v3_22072019.pdf
 4 Designing a Visually
Comfortable Workplace
Jennifer Long
Standards Australia

CONTENTS
Visual Design of Computer Interfaces......................................................................40
Visual Ergonomics Design Elements of Control Rooms.......................................... 42
First Encounters................................................................................................... 42
Wishes Can Come True........................................................................................ 43
Good Intentions Don’t Always Go to Plan...........................................................44
When Plans Go Well, It’s Magic!......................................................................... 45
Success versus Failure.............................................................................................. 45
Communication.................................................................................................... 45
Egos......................................................................................................................46
Conclusion................................................................................................................ 47
References................................................................................................................. 48

As a teenager, I spent many hours contemplating what my future career would be and
how I could change the world or, at least, make a difference for some of the people
who lived in it. I was certain I wanted a s­ cience-based career but was torn between
engineering and optometry. I originally placed engineering on the top of my univer-
sity admissions form, but at the 11th hour swapped it to optometry because I felt a
greater calling to help people to see better. It was such an ­angst-ridden time making
a binary choice for my career path when I was 17 years old. Who would have guessed
that a career path commencing in optometry would eventually intersect with the
engineering/­built environment world? But it did. And it was through this intersection
of careers that I found an avenue for making a difference in this world.
In the early 1990s, there was a vast increase in the number of people using a
computer at work. As an optometrist working in clinical practice, I observed a cor-
responding increase in the number of patients who presented for an eye examination
reporting sore eyes and headaches which they attributed to using a computer. But
when I examined their eyes, there was often nothing wrong. I was intrigued, “­What’s
going on with these patients?” I started to question these patients about their work
and found that the most likely problem was the way that their computer was set up,
the display of their information on their monitor, the quantity and quality of office
lighting, or the fact that they did not take rest breaks during the day.
Unfortunately, visual comfort and ability are often overlooked components in
workplace and equipment design. It’s not until people occupy the space or start using

DOI: 10.1201/9781003349976-4 39
40 Ergonomic Insights

equipment that problems are discovered, such as glare causing headaches, com-
puter displays positioned in locations that promote awkward postures, or computer
interfaces with character elements that are difficult to see. Thus, frustrated with my
inability to help these people, I decided that I might be more effective if I could
address these problems at their source, that is, in the workplace.
To achieve my new aim, I went back to university and studied to become an ergon-
omist. I anticipated that instead of giving advice to individuals in the optometry
consultation room, my new career would enable me to give advice to individuals in
the workplace and, ultimately, solve their visual discomfort. My second career as a
consultant specialising in visual ergonomics commenced in 2006. My work broadly
fell into two categories:

• Providing advice to help people who were experiencing visual discomfort

due to the design of computer interfaces.
• Providing advice to help people who were experiencing visual discomfort
due to the work environment.

By about 2008, I realised that I wasn’t making the difference I had envisaged. The
designs and equipment used by people in the workplace had already been built, pur-
chased, or installed. My advice was often limited to suggesting retrofit solutions
which were potentially expensive and not necessarily a good solution. I started to
wonder, “­Wouldn’t it be more effective to identify and solve problems BEFORE
designs are built or workers occupy the space?”
The good news is that I have since had the opportunity to contribute ­evidence-based
visual ergonomics advice to the design process. It hasn’t all been plain sailing. In this
chapter, I present two examples of my work. The first case example describes my
­less-­than-successful attempts to influence the visual design of computer interfaces.
The second case example describes my more successful attempts to influence visual
ergonomics design elements within control rooms. Had I been asked to explain the
difference between the successful and ­less-­than-successful projects, I would nomi-
nate “­communication” and “­egos”.

VISUAL DESIGN OF COMPUTER INTERFACES

I was contacted by the health and safety (­H&S) manager of an o­ ffice-based organ-
isation where employees performed data entry tasks for most of their working day.
Many employees within the organisation were upset with a new computer program
that had been implemented across the business. There was disquiet because the font
size on the display was less than 2 mm high, and some employees found themselves
leaning forward across their desk to read from the display. Another source of irrita-
tion was the fact that the display colours were visually uncomfortable and could
not be modified (­e.g. black font on a dark green background). Consequently, many
employees reported eye strain and headaches by the end of the working day.
“­Can the workers enlarge the font size, so it is easier to read?” I asked.
“­No”, the manager replied, “­The interface elements have a fixed design”.
“­Can you change the computer monitors or the screen resolution?”
Designing a Visually Comfortable Workplace 41

“­No”, the information technology (­IT) manager informed me, “­The program has
been designed for use on a specific size monitor and screen resolution. If we change
the monitor or the screen resolution, it only makes the problem worse”.
“­Can you describe the problem to the interface designer and ask them to modify
the program?”
The IT manager was adamant. “­No, we have already purchased the program. We
cannot make major design changes like that”.
“­Can you revert to using the old program while you sort out a solution?”
Both the H&S manager and IT manager were aghast. “­Are you kidding??? The
business has just spent several million dollars on this new program! It has to work!!!”
I wish that the above were an isolated anecdote. Unfortunately, variations on these
conversations litter my visual ergonomics consultancy career. Nevertheless, I thought
I struck gold when I was invited by the site ergonomist of an industrial plant to speak
to employee engineers about the computer displays used on site. These engineers had
some influence over the computer interface design. The site ergonomist thought it
would be useful if I could explain the rationale behind the interface design elements
so that the engineers were more informed when making design decisions.
During the education session, I shared visual ergonomics pearls, such as why the
font needs to be a minimum size so employees don’t need to lean across their desk
to read from the display (­Rempel et al., 2007). Also, why it’s not a good idea to use
red font on a blue background1 (­Travis, 1991). At the end of the session, one of the
engineers exclaimed, “­I wish someone told me this years ago! Now the design rules
make more sense”.
However, my connection with the industrial site ceased when the site ergonomist
changed her employment. As such, I could not know what changes the engineers
were able to implement with their computer interfaces. Nevertheless, I have had simi-
lar interactions with engineers in subsequent consultancy projects across a range of
industries. When I’ve explained the rationale for the design rules, their responses
have been almost unanimous, “­I wish someone told me this years ago!”
Interestingly, although organisations may employ engineers and IT specialists as
permanent staff to help design and implement computer interfaces within their busi-
ness, I’ve observed that the design influence of these employees is often limited. For
example, while working on a project to redesign a control room, there was an engi-
neer who was assigned to work with the software company who were developing the
computer interface. The engineer had identified potential problems with the interface
that was going to affect its usability and the visual comfort of the control room opera-
tors. The problems were unresolved, despite several conversations and meetings with
the software developer.
The engineer thought he might have more success resolving the potential interface
problems if he armed himself with some solid facts. He attended the next meet-
ing with the software developer equipped with Hollifield’s High Performance HMI
Handbook (­Hollifield et al., 2008) and informed with the visual ergonomics knowl-
edge learnt from me. Unfortunately, these resources were insufficient to penetrate the

1 This sets up chromostereopsis, an optical effect where the page appears to shimmer, caused by the fact
that our eyes are unable to simultaneously focus on the red and blue colours.
42 Ergonomic Insights

veritable steel wall surrounding the software company and its representative, who
repeatedly uttered, “­This is the base design. If you want to change the base design,
then it will take several years for a dedicated team to do this”. Of course, it would
also require vast amounts of money to create a bespoke solution. The consistent mes-
sage implied by the software company was that other clients weren’t complaining
about the base product, so why should they modify it? I wish this was another iso-
lated anecdote, but variations on this scenario have also been common throughout
my visual ergonomics consultancy career.
Maybe it is naïve on my part, but it mystifies me why software development
companies are seemingly unaware of basic visual ergonomics knowledge that can
improve the usability and comfort of their designs. This knowledge is in the public
domain and published in standards, books, and even on the Internet. I’ve asked soft-
ware developers while working on projects, as well as people I know socially who
work in the industry, “­What are the barriers to implementing good design elements?”
My question has usually been met with a bemused look and a shrug of the shoulders
to convey “­I don’t know”.
My hope is that the small amount of work that I have done with engineers within
companies, together with the recommendations I’ve written in reports, will be
adopted in future iterations of software used within those organisations. Maybe, little
by little, this will improve the visual comfort and ability of the people who use these
systems. Ideally, I would like to see an i­ndustry-wide approach to improving the
visual design of interfaces, for example, by including visual ergonomics education
within engineering curricula so that software engineers understand the rationale for
design decisions. This could be coupled with greater consumer awareness of good
visual design elements, for instance, by including visual ergonomics criteria in the
design and procurement phases of products.

VISUAL ERGONOMICS DESIGN ELEMENTS OF CONTROL ROOMS

First Encounters
My first encounter with a control room was early in my consultancy career. I was
contacted by the H&S manager of an industrial plant because operators in the con-
trol room were unhappy. Some operators described difficulty seeing the displays and
visual discomfort by the end of their ­12-hour shift. I was engaged to give advice
on how to improve the visual comfort and ability of the control room operators.
I was expecting an ugly environment, but, to my surprise, the control room was
­well-appointed and aesthetically pleasing. In hindsight, this was one of the better
control rooms I have visited during my career. On the other hand, unfortunately, the
problems described by the control room operators were not easy fixes.
The operators were using ­two-tier, vertically stacked displays on their console.
The upper displays were above eye height, necessitating a h­ ead-­tipped-back pos-
ture to read from the displays. This is not an ideal physical arrangement because
it can contribute to neck and shoulder discomfort. It is also contrary to ergonom-
ics best practice, which recommends that frequently used displays should be below
eye height (­­Burgess-Limerick et al., 2000; ISO, 1999; Villanueva et al., 1996). The
Designing a Visually Comfortable Workplace 43

uncomfortable posture was even more pronounced for operators aged over 40 years
who were wearing ­general-purpose progressive lens spectacles or ­general-purpose
bifocal spectacles to correct the optical effects of presbyopia.
Presbyopia is a normal ­age-related change that reduces the eye’s ability to easily
adjust focus between close and far distances. People typically notice difficulty seeing
objects up close, and it is easily remedied with reading spectacles. ­General-purpose
progressive and bifocal spectacles are ideal for people with presbyopia who want one
pair of spectacles that allow them to see objects at a close distance (­e.g. for reading)
and objects at a far distance (­e.g. for driving). The near vision zone is in the lower
portion of the spectacle lens, enabling the wearer to simply look downwards to view
­hand-held objects such as books or smartphones. However, the location of the read-
ing zone in the lower portion of the lens promotes a ­head-­tipped-back/­chin thrust for-
ward posture when wearers try to read from a desktop computer display (­Martin &
Dain, 1988). Consequently, ­general-purpose progressive and bifocal lenses are con-
traindicated for desktop computer tasks (­Long, 2019).
The optimal solution for the control room was to redesign the computer interfaces
and replace some of the displays on the consoles. This would ensure a more com-
fortable height for operators seated at the console but was beyond the budget of the
business at that time point. I discussed possible solutions with the manager, including
repositioning frequently used display content onto lower tier displays that were below
eye height. We agreed my report should provide advice for what the business should
consider next time they built a control room, as well as advice on how to manage the
existing problems.
My report also included recommendations for alternative types of spectacle lenses
that operators should wear while working at their console to reduce their risk of neck
and shoulder discomfort from viewing displays above eye height (­Long, 2019). While
I know that my report was focused heavily on o­ ptometry-type advice, I felt that I had
made a step forward in solving vision problems at their source. However, in making
this step forward, I also discovered that “­the source” was not really the workplace. It
was higher up, that is, with the people who designed the control room. My lingering
question was “­How can I work with someone to design better control rooms?”

Wishes Can Come True

For several years, I continued to provide visual ergonomics advice in control rooms
that were already built and operational. Each time, I provided advice on what I con-
sidered the business should incorporate when they upgraded their control room as
well as simple retrofit solutions that would improve the comfort of operators working
in the room. One day, I received a phone call from a control room architect. He had
read a report I had submitted to a mutual client. He shared my philosophy that it is
better to design out problems before they are built into a system. I was invited to work
with him and another ergonomist to provide very early schematic design advice for
control rooms.
My role in the team was threefold: provide visual ergonomics ­evidence-based
information that would inform good design, help discover the stakeholder require-
ments for the control room, and assist facilitating participatory ergonomics
44 Ergonomic Insights

workshops with the control room stakeholders, including control room operators,
managers, ancillary staff, IT support staff, and facility managers (­Long et al., 2019).
Participatory ergonomics is an interactive process whereby stakeholders are pro-
vided with ­evidence-based ergonomics knowledge and design principles relevant to
their workplace. Through facilitated workshops, the stakeholders are supported and
encouraged to apply their own knowledge of the work and work tasks to solve work-
place ergonomics problems (­­Burgess-Limerick, 2018). The education component of
this process was critical because it helped the stakeholders understand the implica-
tions of design decisions without placing constraints on the appearance of the control
room. We encouraged the stakeholders to think outside the box for design solutions.
Once the stakeholders realised that all brainstormed ideas were of value, the process
was generally fun and resulted in good design suggestions.
Some of the visual ergonomics issues that we canvassed during this process
included lighting that enables good visual comfort and function, the number and
location of visual displays to promote good physical posture and ease of viewing,
and lines of sight within the control room to facilitate good working relationships. If
the very early schematic design was subsequently adopted by the business, then other
professionals (­e.g. lighting designers, architects, and builders) were contracted to
interpret the very early schematic design, create an architectural and lighting design
to meet the brief, and then build the facility.

Good Intentions Don’t Always Go to Plan

Some of the early schematic design projects with smaller size clients progressed
seamlessly to a built solution. This was encouraging. Instead of retrofitting solutions
to existing control rooms, I was seeing built solutions that addressed visual ergonom-
ics problems. I was making a difference! However, good intentions don’t always go
to plan, especially with larger size clients. Sometimes, we, meaning the control room
architect, another ergonomist, and me, found ourselves enmeshed among layers of
project managers and subcontractors. All were involved in the design and build of the
facility, but each had their own agenda and opinion.
In one case, the client wanted us to collaborate with the fi
­ t-out team to ensure the
very early schematic design was translated into the built design. However, the con-
tractor agreement was structured to keep our working team separate from the ­fit-out
team. The project manager did not appreciate the importance of user engagement
and the ergonomic design process and expected that the control room and visual
displays would be arranged in a p­ re-conceived way because “­that is what a control
room should look like”.
Unfortunately, this was different to the requirements articulated by the user
groups. I found this frustrating because we had spent many hours discovering the
needs of the various stakeholders who were very clear about what would and would
not work for them in their work environment. In addition to that, the design envis-
aged by the project manager had several flaws, including workstations located in
positions that did not enable good lines of sight between operators or good lines of
sight to a large ­wall-mounted display. These design flaws would make the work of the
operators more difficult and uncomfortable.
Designing a Visually Comfortable Workplace 45

Although visual ergonomics advice was contained within a report underpin-

ning the design rationale, the advice was not adopted by the lighting designer or the
­built-design architect. The latter was the person who created an architectural design
based on our schematic design and oversaw the construction of the control room.
There was also poor communication with the b­ uilt-design architect, and no commu-
nication with the lighting designer during the design and build process.
Subsequently, the visual ergonomics elements incorporated into the built product
were contrary to visual ergonomics best practice. For example, we specified light-
ing that would not be a direct glare source for operators when they viewed the large
­wall-mounted display or communicated with other colleagues in the room. Also, we
specified lighting that would not cause specular, ­mirror-like reflections on displays,
obscuring critical information that operators needed to see. The built product did not
meet these requirements. The ceiling luminaires were a glare source when operators
looked up from their console and were visible as reflections on computer displays,
making the displays unreadable. The end users were dissatisfied with the general
lighting in the control room, and they switched it off to manage these visual ergo-
nomics problems. This was such a disappointing outcome, especially when consider-
ing these problems were identified before the facility was built.

When Plans Go Well, It’s Magic!

On a more optimistic note, I have observed that success is more likely when there is
good collaboration among the various design entities. In another project with similar
objectives, the control room architect, another ergonomist, and I had a good working
relationship with the b­ uilt-design architect. The latter attended the design workshops
and contributed to the discussions when required. His role in the project included
contracting and liaising with a lighting designer.
I provided visual ergonomics advice as part of a larger report that described the
rationale for the early schematic design. The report was read by the b­ uilt-design
architect who translated our recommendations to an architectural design. During
the build stage, the b­ uilt-design architect oversaw the work of the lighting designer.
Although I didn’t have the opportunity to work closely with the lighting designer, the
­built-design architect facilitated a discussion between me and the lighting designer
about lighting products that would meet the design brief. The challenge with this
project was a relatively low ceiling height in the control room that made it tricky to
illuminate without causing reflected glare on the desktop or ­wall-mounted displays.
Fortunately, the lighting designer was able to source appropriate products, and the
visual ergonomics elements and lighting in the built design were reported comfort-
able by the end users.

SUCCESS VERSUS FAILURE

Communication
In the first case, I described my attempts to influence the visual design of computer
interfaces. I was coached on how to best communicate with the plant engineers by
46 Ergonomic Insights

an o­ n-site ergonomist who worked closely with the engineers. She understood which
strategies were best to capture the attention of the engineers and explained how I
should present information to capture the engineer’s attention. She taught me the
language of the engineers.
In the second case, I described my fortune in being able to realise my goal to elim-
inate visual ergonomics problems in the physical design of control rooms. I think this
was successful because I was engaged by a control room architect who was familiar
with the design and build process and could navigate the contractual process and
speak the ­built-design language with the various stakeholders.
To date, I have developed skills which allow me to predict potential visual ergo-
nomics problems by looking at ­two-dimensional architectural drawings and visualis-
ing what the design will look like in a t­ hree-dimensional space. However, I have not
mastered the language to converse with builders to prevent visual ergonomics prob-
lems in a built product. Working with the control room architect gave me the ability
to have my knowledge translated into ­built-design language.
I also think that there is an element of respect and trust when colleagues from the
same profession converse with one another. This can help lubricate communication
channels. In the second case, the control room architect and the ­built-design architect
had worked with each other on a previous project and enjoyed shared memories of
events that had occurred within their profession. This smoothed the way for a good
working relationship. It would have taken a lot more time, extending beyond the proj-
ect timeline, for me or the other ergonomist to build this type of rapport.
Respect and trust of fellow professionals might also explain the difficulties I
described in the first case about display interfaces. I do not have a computer sci-
ence or software development background, meaning I do not have the ability to flu-
ently converse in “­­computer-speak”. I accept this limitation. However, the engineers
employed by my clients did have computer science backgrounds and were fluent in
­computer-speak. Still, they could not gain traction in conversations with the software
developers. Admittedly, there might have been genuine technical reasons for the soft-
ware developers not being able to modify the software base products. Nonetheless,
should the engineers requesting the changes have also been software developers, I
wonder whether the conversations and implementation of software changes would
have been more successful.

Egos
Of course, when we work in multidisciplinary teams, egos are likely to rear their
head. This is even more likely when the discussions include challenging another pro-
fessional about their design ideas. I think that “­ego” was a strong factor in the case of
the visual design of display interfaces. When challenging the engineers to modify the
interface design, the software developers argued, “­­No-one else has complained. Why
are you telling us that we are wrong?” It was almost certainly a factor in the second
case when developing an early schematic design for the ­large-size company wanting
to build a control room. There were stakeholders keen to make their stamp on the
design, even if it was contrary to the wishes of the operators who were ultimately
going to occupy the space.
Designing a Visually Comfortable Workplace 47

Possibly, in working on the design of control rooms, one would think that I had
developed close working relationships with lighting designers. Unfortunately, this
was not the case. Although we asked our control room clients to invite the project
lighting designer to ergonomics workshops with the stakeholders, very few light-
ing designers took up the opportunity. This did not always have an adverse effect.
Some lighting designers provided elegant lighting solutions that met the user require-
ments and worked well in the control room. On the other hand, we also witnessed
some interesting interpretations of the lighting design requirements, usually where
the designer was intent on expressing their artistic flair (­e.g. pendant luminaires that
obscured the operator’s view of ­wall-mounted displays, and linear extrusion ceiling
luminaires that caused specular reflections on w­ all-mounted displays). In these cases,
the design solution was detrimental to a visually comfortable control room.
At a professional level, the lighting industry recognises that multidisciplinary
collaboration can be an integral component of a built design. The ­American-based
Illuminating Engineering Society has hosted professional development forums to
discuss collaborative opportunities for lighting designers. They recently invited me
to write a blog for their website outlining my control room work and the advantages
of multidisciplinary collaboration (­Long, 2020). However, I have not experienced a
good collaborative relationship with a lighting designer on a control room project,
except for the instance described in the second case. In that project, the b­ uilt-design
architect was the mediator in a conversation between me and the lighting designer.
I was puzzled. How could I work with lighting designers? What is the barrier to
a more fruitful engagement? To help me understand this, I chatted with a lighting
designer recommended to me by a colleague. He candidly informed me that he would
prefer to gather his information for the design brief in the way that he was accus-
tomed. This preference would not change even if he was provided with a design brief
already prepared by me and my colleagues based on the results of the ergonomics
workshops with stakeholders. When I asked, “­Should I do something different which
would promote collaboration with lighting designers?”, he disclosed that he would
find it intimidating being in a room with people like me who had multiple academic
degrees. I suppose that he was trying to tell me in a polite way that he thought I was
an academic boffin that did not know what I was doing. As such, he would prefer to
do the work himself. I know this is only one designer’s opinion, and that I might gain
other insights if I canvassed the opinions of other lighting designers. Nevertheless, it
gave me a pause. Ergonomists frequently have undergraduate and postgraduate qual-
ifications, and some have doctorate degrees. Is our high level of education a potential
barrier to multidisciplinary collaboration? Or do we need to find more accessible
language and approaches to gain the trust of our design colleagues?

CONCLUSION
I have been on an interesting quest during the past 30 years. My inability to solve the
vision problems of my patients in the optometry consultation room led me to a career
in ergonomics where I have endeavoured to make a difference in people’s lives by
improving the visual design of display interfaces and improving the physical design
of control rooms.
48 Ergonomic Insights

My belief that good design will ameliorate many of the visual symptoms that
people experience at work has been vindicated. I have been fortunate to contribute
­evidence-based visual ergonomics advice in control room projects. This has helped
to create successful designs where the end users were satisfied and visually comfort-
able in their work environment. I wish I was more successful in influencing display
interface design. Still, I quietly hope that my recommendations contained in ergo-
nomics reports will be adopted in future iterations of software.
If I were giving advice to my younger self, then I would emphasise the importance
of good communication with colleagues and stakeholders. If you cannot speak the
professional language of the stakeholders, then find someone who can teach you the
language or someone who can translate what you want to say into words that the
stakeholders can understand. In my work with computer interfaces, I didn’t master
­computer-speak. I believe that this was a barrier for enabling improvements to inter-
face design. However, in my work with control rooms, I was taught ­engineering-speak
by colleagues. I worked with an architect who could translate my visual ergonomics
advice into words and images that other professionals working in the b­ uilt-design
environment could understand.
My second piece of advice to my younger self would be to reassure her that differ-
ences of opinion are a normal part of professional life. What matters is how you react
and try to manage the differences. Unfortunately, some professional relationships are
binary, win or lose. It effectively comes down to the question, “­Did the good or bad
design win?” However, it does not have to be that way. In our ergonomics workshops
with stakeholders, we brainstormed ideas, and all ideas were respected, noted, and
discussed. Once participants realised this, the process became fun and productive.
Together, we generated design ideas that went beyond what we envisaged at the start
of the workshop. Maybe, this is a lesson that we can take with us to our ­real-world
interactions with other people: diverse ideas from different professionals may lead to
conflict but, if ­well-managed, can result in robust practices and innovation.

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 5 Opportunities and
Challenges for Designing
Quality Work in
Residential Aged Care
Valerie O’Keeffe
Flinders University

CONTENTS
Setting the Scene....................................................................................................... 52
Good Work Design: Matching Demands with Resources.................................... 52
Job Crafting.......................................................................................................... 52
The Context and Its Actors....................................................................................... 53
The Discovery Journey............................................................................................. 55
The ­Co-design Journey............................................................................................. 57
The Realisation Journey............................................................................................ 59
Designed with Care: Successes and Failures............................................................60
The Lessons Learned................................................................................................ 61
References................................................................................................................. 62

Residential aged care services face unrelenting pressures from a growing ageing
population, workforce shortages, and rising costs of care, impacting care workers’
health and safety and capacity for quality care (­Hodgkin et al., 2017). Incidents
related to worker and client safety and service quality (­i.e. errors and missed
care) arise from the design of work and can be minimised through systematic
work analysis and redesign (­Carayon et al., 2006). Interventions are most effective
when they address safety and service quality problems at the source, such as high
workload, staff shortages, and inadequate resources (­Oakman et al., 2019). The
intervention case titled Designed with Care (­DWC) arose from concerns from the
work health and safety (­W HS) regulator about high rates of ­work-related muscu-
loskeletal disorders (­W MSDs) and psychological injuries affecting care workers
across the aged care industry. The goal was to reduce physical and psychologi-
cal injury by trialling a work design intervention in an organisation to tackle
upstream risk factors.

DOI: 10.1201/9781003349976-5 51
52 Ergonomic Insights

SETTING THE SCENE

Good Work Design: Matching Demands with Resources
Good work design (­GWD) recognises that interventions are most successful when
they are organisationally directed and ­ systems-focused, considering dependen-
cies between people, tools, and their physical and social environments (­Karanikas
et al., 2021). Effective work design matches work demands (­i.e. features of work)
with resources (­i.e. aspects supporting the achievement of work goals) to meet
those demands. Job resources can make it possible to deal with job demands and/­or
promote personal growth and development (­Demerouti et al., 2001). Mismatched
demands and resources lead to energy depletion, a situation that erodes health and
produces poorer quality work outcomes (­Demerouti et al., 2001).
Demands include the physical and mental content of work (­i.e. its variety and
complexity), workload (­i.e. the effort required), exposure to the physical environment
(­e.g. temperature, noise, air quality), and work organisation (­e.g. time pressure and
hours/­timing of work). Organisational resources include job control, skill develop-
ment and utilisation, participative ­decision-making, and task variety, while social
resources include support from supervisors, colleagues, friends, and family. Where
job demands are high, the impact of resources becomes more critical to sustaining
performance (­Tims et al., 2013). Features of good work include having task vari-
ety, manageable workloads, feedback, participative ­decision-making, skill use and
autonomy, supervisor and ­co-worker support, and fair remuneration (­Clarke, 2015).
GWD also motivates individuals to improve their own jobs by crafting solutions to
match challenging demands and available resources. It begins with a problem and/­or
an opportunity to improve work. In the DWC case, WMSDs and psychological inju-
ries were the problems to solve, and better client care and worker job satisfaction were
the opportunities to realise. GWD is an iterative and participative t­ hree-stage process
of Discovery, Design, and Realisation. Discovery involves understanding problems
and/­or opportunities through engaging people affected by the work and examining
the work itself. Design involves p­ roblem-solving, identifying solutions and strategies
to model or trial options, and preparing for change. Realisation involves implement-
ing solutions, innovating, and improving performance (­Karanikas et al., 2021).

Job Crafting
The DWC intervention aimed to optimise the balance between work demands and
resources through changing work structures at the system level. Job crafting repre-
sents the proactive changes workers make to design their work to initiate positive
outcomes, and it promotes engagement, job satisfaction, and resilience. Job crafting
focuses on workers’ opportunities to customise and actively modify their tasks and
interactions with others. Tasks can be expanded or reduced in scope, the nature of
relationships with others can change, or perceptions of work can be reappraised to
view tasks collectively as having a broad purpose or goal (­Berg et al., 2008).
Job crafting requires high levels of work engagement, evident as an active, positive
­work-related state of vigour, dedication, and absorption (­Bakker, 2011). ­Co-worker
Opportunities and Challenges for Designing Quality Work 53

­FIGURE 5.1 Model of work engagement incorporating job crafting (­Based on Bakker &
Demerouti, 2008.)

support, performance feedback, skill variety, autonomy, and learning opportunities

promote work engagement, where workers harness motivation to adjust demands,
resources, or both. Job crafting becomes even more significant when demands are
inherent in the job itself, as in aged care, and not easily modified (­Cooley & Yovanoff,
1996). Given the significant recent restructuring in the host aged care organisation of
this case, the DWC intervention focused on increasing care staff resources through
job crafting, as depicted in F ­ igure 5.1. An intervention bolstering personal and job
resources was expected to increase work engagement and improve job performance
by increasing capacity to respond more effectively to high job demands.

THE CONTEXT AND ITS ACTORS

The mission of the aged care provider involved in this project is to be a leader in
providing quality residential care for aging clients based on Christian principles
that maintain the dignity, rights, and values of the individual. Organisational values
also reflect respect for people and their right to live in a ­home-like environment.
The organisation aims to provide ­best-practice ­person-centred care delivered by
highly trained staff with adequate resources and time to fulfil their roles effectively.
Following a period of organisational change and restructure, the organisation expe-
rienced the following:

• Restructuring of roles and responsibilities, with significant changes in key

personnel in the Head Office and onsite;
54 Ergonomic Insights

• Extensive review of rostering and hours, generating high dissatisfaction

among care staff;
• Introduction of a new case management model; and
• Introduction of a new restraint policy.

The organisation came to the project aiming to embed the new case management
model of care, while concurrently improving care staff’s job quality. Following the
review of rostering and hours, the organisational appetite to change structural aspects
of care work was low. Nonetheless, the project provided opportunities to adopt the
new model as a vehicle for enhancing direct worker participation in care and promot-
ing job satisfaction.
Wisteria Gardens (­a pseudonym) is one of the several sites operated by the
involved n­ ot-­for-profit residential aged care provider in Australia. It provides services
to tens of residents delivered by tens of staff in a modern, d­ ementia-friendly facil-
ity designed with ­home-like units, on the metropolitan fringe of a capital city. The
organisation’s senior management selected Wisteria Gardens for the intervention due
to its stable and supportive staffing, and minimal anticipated disruptions from the
­organisation-wide building and refurbishment programme at the time.
The residential site manager has responsibility for administration and customer
services, WHS, hotel and property services, clinical care, continuous improvement,
and lifestyle and pastoral care. The clinical nurse manager supervises four clinical
leaders who ensure high standards of clinical care through their supervisory role
of direct care workers, the latter including enrolled nurses and personal care atten-
dants. The new clinical leader role was the centrepiece of the intervention, seeking to
expand their supervisory skills and strengthen care worker contributions to improv-
ing care.
My role as an ergonomist was to be a knowledgeable facilitator. Trained as an
allied health professional, I brought familiarity with the health and w ­ ell-being issues
of eldercare, allowing shared language, and understanding of current work practices
from care staff perspectives. I facilitated a ­co-design process where problems were
structured and solutions were identified collaboratively with care staff and man-
agement. Ideally, a ­co-design process would include consumers of care in framing
problems and opportunities. However, management did not include consumer per-
spectives as they considered the intervention primarily a WHS initiative.
Indeed, the project premised that risks are inherent in the work itself and improv-
ing work design would be beneficial for reducing worker injuries and enhancing cli-
ent care outcomes. However, in the six months’ time between applying for funding
and commencing the project, the provider experienced extensive change, including
the loss of the project sponsor. The organisation was ­change-weary, leading to dif-
ficulty in gaining new management’s trust and commitment. They were reluctant to
embark on further change, concerned that issues arising from the previous change
would be reignited.
Challenges also arose in gaining care workers’ trust and confidence in the inter-
vention. Recent reviews of hours and rosters left care staff cynical that positive
change could be realised, and they were feeling little enthusiasm for participating in
a ­project-steering group since they were ­time-poor and fatigued. Strategies to build
Opportunities and Challenges for Designing Quality Work 55

commitment and participation included identifying workers of influence, providing

them with information to promote the project, and fostering grassroots optimism that
­small-scale changes could be achieved.

THE DISCOVERY JOURNEY

Since the problem was initially related to injury occurrences, WHS data could
inform the extent and nature of injuries. The WHS regulator provided data describ-
ing occurrences of WMSD and psychological injuries across the state’s aged care
industry. We compared these with data from all worksites of the aged care provider,
including Wisteria Gardens. Data were collected for the four years before commenc-
ing the project and were evaluated as percentages of total claims. Over that period,
the organisation experienced 310 accepted workers’ compensation claims, with 23
(­7.4%) occurring at Wisteria Gardens, showing the site performed slightly better than
most other sites with about 9% of the total claims each.
The organisation experienced a higher proportion of claims for WMSD (­49.7%)
than the industry overall (­44.5%), but performed better with lower psychological
claims than the industry (­2.6% vs 4.4%). However, this could suggest the possibil-
ity of reluctance to report. I noted that at Wisteria Gardens, they collected injury
and incident data for all classifications of potential injury events (­i.e. report only,
first aid only, and medical treatment claims) and included injuries directly resulting
from client behaviours. Collectively, these data provided a baseline for designing and
evaluating solutions.
Injury data draw a picture of what injuries are occurring, when, where, and to
whom, but are less informative about how injuries arise during work. Interviews
and surveys support a more holistic assessment of the interactive nature of risks,
accounting for the job in its whole social and organisational context. These meth-
ods identify upstream factors less evident in ­task-based analyses of technical risk
factors. Surveys and interviews also enable participation and expressions of diverse
knowledge, bringing rich insights from those with fi ­ rst-hand experience. My clinical
experience had armed me with intimate knowledge of how care work is constructed,
and that it depends on effective teamwork between colleagues and clients. Interviews
are critical in understanding and designing good work because they tap that tacit
knowledge and dynamic interplay between people and tasks and reveal how staff
flexibly respond to needs, wants, and challenges.
Fourteen care staff from all units participated in the discovery phase interviews.
Interviewing care staff during work time is challenging as staff are ­time-pressured,
and it is difficult to relieve them for around 30 minutes without interruption. Also,
influenced by perceived cost pressures, releasing care workers to take part in inter-
views required ongoing negotiation with management, despite the funding proposal
budgeting for reimbursing their time. Strategies to counter these challenges included
engaging management regularly in developments, emphasising and paying close
attention to enacting the ­co-design process and principles, and responding promptly
to questions and concerns using the best evidence. As an external facilitator, I regu-
larly provided examples from other workplaces in aged care and broader industry
to explain the rationale for how improvements in work design would benefit care.
56 Ergonomic Insights

Having had experience in aged care and broader industry helped to build credibility
with the Wisteria Gardens team, and confidence I would bring new perspectives and
question the status quo.
During the interviews, I invited participants to describe their work, what they
liked most and least, the greatest demands and priorities, risks to their health and
safety, their involvement in d­ ecision-making, and the characteristics of workers most
valued in the facility. I also provided participants with a summary of the injury statis-
tics analysis and e­ vidence-based information about the shared causative mechanisms
for WMSD and psychological injuries. I prompted them to reflect on this informa-
tion and identify simple changes that they believed could improve their work while
maintaining service delivery.
The interviews revealed workers did not feel adequately skilled or supported
when dealing with the challenging behaviours of some residents, and the impact of
workload made it difficult for them to be ‘­present’ and provide individualised care.
Staff also felt that the residents’ right to a ­home-like environment was prioritised
above the workers’ right to a safe workplace. The carers also highlighted concerns
about manual handling when responding to residents with challenging behaviours,
given the recent changes in the restraint policy. Consistent with best practices in aged
care policy, the review of the restraint policy led to bed rails being eliminated, and a
gradual introduction of new beds and associated manual handling equipment, includ-
ing hoists, bed poles, and sensor mats. Overall, the interview findings emphasised the
busyness of the work environment, the challenge of communicating and coordinat-
ing work, and the desire of care staff for greater support.
Additionally, I administered anonymous surveys seeking care workers’ percep-
tions of work design factors to assess the risks and opportunities for improving
care work. Surveys examined four constructs involving qualitative and quantitative
variables: body part discomfort (­Dawson et al., 2009), job demands and resources
(­Karasek et al., 1998), work engagement (­Seppälä et al., 2009), and psychosocial
safety climate (­PSC) (­Hall et al., 2010). I distributed the surveys in online and hard
copy formats through staff emails and mailboxes, in the staff room, and through
direct personal invitations. The responses to the survey highlighted that carers expe-
rienced considerable levels of mental and physical fatigue and localised body part
discomfort, plus high physical and mental work demands.
Furthermore, to gain a nuanced understanding of the organisational culture and
practices, I attended the site one day each week during the nine months of the proj-
ect. Work occurs within a context that reflects organisational values, and success-
ful interventions must consider that context (­Zadow et al., 2017). My purpose was
to shadow staff during daily activities across morning and afternoon shifts. This
built relationships and trust, enabled observations of work practices and interactions
between staff and with residents, and offered an opportunity to review organisational
documentation (­e.g. enterprise agreements, job descriptions, annual reports, policies
and procedures, and training material).
The organisational scan revealed a comprehensive manual handling programme
in place, including regular reviews of controls, integration with care planning, main-
tenance of equipment, and targeted training. The organisation had also implemented
an industry ­award-winning dementia care programme built on honouring residents’
Opportunities and Challenges for Designing Quality Work 57

dignity, choice, and individuality. Following the recent direct care staff rostering and
hours review, direct contact for care at Wisteria Gardens was on average 3.3 hours/­day
and per resident. The industry standard is 2.84 hours/­day. Comparable to Australia,
Canadian standards require 3.0 hours per resident per day of direct care (­Eagar et al.,
2019), while research on missed care suggests an average of 4.3 hours/­day is necessary
to provide quality care (­Willis et al., 2016). Hence, Wisteria Gardens was sitting some-
where between the industry average and evidenced standard of quality care provision.
Combined, the findings from the interviews, surveys, and the organisational
scan highlighted the potential value of increasing structured communication and
­information-sharing to facilitate planning and p­ roblem-solving in a ­time-pressured
environment. Providing quality aged care services is challenging, given the expec-
tation to respond to increasing service demands, and the growing complexity and
individualised care needs of residents. These factors intensify the physical and psy-
chological demands placed on care staff. Considering management reluctance to
revisit recent modifications to rostering and staffing, and the systemic sources of
these risks, ­large-scale work design changes were deemed unfeasible. Yet, this project
provided an opportunity to highlight the value of s­ mall-scale localised approaches to
improving work and its outcomes.

THE C
­ O-DESIGN JOURNEY
Designing solutions is a recursive process requiring imagination, creativity, and
innovation stimulated through active participation by those affected by the work.
Review and integration of evidence gathered in the discovery process must also
inform design. It is worth remembering that solutions often need to meet various cri-
teria beyond addressing the central problem, acknowledging that some demands are
inherent in the work and not easily altered without ­large-scale transformation. The
DWC intervention had to be s­ mall-scale, benefit care, not incur organisational costs,
and improve job resources to reduce risks of WMSDs and psychological injuries.
Indeed, the process of developing solutions to an implementable state often identi-
fies gaps in knowledge and necessitates further discovery to collect fresh evidence
and inform how to embody and apply a solution. Some ideas may innovate and
advance another idea, so all ideas are potentially rich sources of insight and should
not be hastily discarded. My experiences working in engineering sciences to imple-
ment technology in production processes have shown me the value of studying how
other industries have solved similar problems and testing and trialling tools and tech-
niques at a ­micro-scale as proof of concept. Small wins garner support and motiva-
tion to try further improvement ideas, building momentum for GWD.
As workplace participation is essential for designing safe work (­Pehkhonen et al.,
2009), we adopted a ­co-design approach. To be sustainable, job design improvements
should concentrate on psychological risks and WMSD prevention and improve stan-
dards of care and overall business performance. Cultivating improved communica-
tion among care staff as a job resource was chosen as the focus of the intervention.
Improved communication is effective in modifying risks for WMSDs and psycho-
logical harm arising from the high physical and psychological demands (­Wagner
et al., 2015).
58 Ergonomic Insights

Traditional documented communications often fail. They can be t­ ime-consuming

and cannot readily capture the dynamism of aged care work because employees are
less inclined to document subtle changes. Formal reporting processes often miss
much of the fluid nature of r­ eal-time interpersonal exchanges that support spontane-
ous problem identification, generate solutions, and share ideas. The reality of care
work involves tensions between time pressures and responses to individual client
needs. Dynamic approaches are timely, are responsive, and support ‘­making sense’
of clients’ cues, organisational goals, and staff safety and ­well-being (­O’Keeffe et al.,
2015). Thus, care staff could benefit from interactions through sharing experiences
and collectively ‘­make sense’ of these in the context of their work.
As focus groups are valuable mechanisms for generating ideas and selecting solu-
tions, I facilitated separate focus groups involving management and a representative
sample of eight care staff to reflect on the discovery phase findings and feasible
solutions. Both groups agreed to trial an intervention introducing structured com-
munication tools to underpin more effective and responsive p­ roblem-solving and
­information-sharing during delivery of care.
The ­co-designed intervention was a structured p­ roblem-solving approach and
we named SHARE4CARE that could be used in various settings in the aged care
work environment. It was inspired by the tool STOP and WATCH (­Ouslander et al.,
2014) and the Team Strategies and Tools to Enhance Performance and Patient Safety
(­TeamSTEPPS) programme (­Guimond, 2009). The SHARE4CARE acronym sum-
marises the communication process and skills required for ad hoc ‘­­ on-­the-go’
­problem-solving:

S = Stop, speak
H = Hear (­listen)
A = Acknowledge or ask more questions
R = Reflect
E = Engage together
4 = 4 ­minutes – the time that the process should take
C = Coordinate
A = Act
R = Review effectiveness
E = Embed improvements into daily practice

SHARE4CARE provided a framework for spontaneous ­problem-solving and com-

munication between two or more carers. The tool encouraged staff to come together
around a specific issue to be resolved, resulting in a shared plan of action and review.
SHARE4CARE also enabled staff to express observations and experiences as inher-
ent in giving care, rather than a collection of technical hazards stripped of their con-
text. This way, we tackled WMSDs and psychosocial risk factors upstream through
work design and the social context where hazards were experienced, rather than con-
straining our views on downstream factors like biomechanical risks.
Additionally, Buzz meetings were the idea of site management to increase staff
participation in care planning for individual residents. These were clinical ­leader-led
­20–30 minutes meetings in each unit that allowed care staff to come together with
Opportunities and Challenges for Designing Quality Work 59

their clinical leader around current issues affecting care and be connected to the
current ‘­Buzz’. Meetings were ad hoc and held across morning and afternoon shifts.
The clinical nurse manager’s goal was to use these sessions to tap carers’ insights
into residents whose care plans and funding were under review. Each meeting had a
topic or resident of focus, supplemented with a general discussion on what was work-
ing well or not in the unit. The SHARE4CARE tool was also used to guide discus-
sion during Buzz meetings. Management and care staff supported implementing the
SHARE4CARE communication tool and regular ad hoc Buzz meetings. Together,
these interventions addressed care staff requests for improved communication,
­information-sharing, and supervisory support.

THE REALISATION JOURNEY

Realisation in the work design process refers to the translation of design outcomes
to deliver tangible benefits for everyone affected by the work, which in this case
included management, care staff, and clients. It involves working closely with work-
place partners to understand the organisational context and ensure implementation
and uptake can be achieved through effective planning, resource allocation, and par-
ticipation. Our communication intervention aimed to enhance information and social
resources to support ­problem-solving and optimise challenge, autonomy, skill utilisa-
tion, and learning.
I introduced the SHARE4CARE tool in a h­ alf-day workshop delivered to clini-
cal leaders and care staff. The workshop began with briefly reviewing the discovery
and design stage outcomes and then presented the SHARE4CARE communication
tool. The rest of the workshop provided theory and practice in using effective com-
munication skills (­e.g. professional, factual, and assertive language, ‘­I’ statements,
managing emotion, active listening, reflection, apologising, and p­ erspective-taking).
Practice involved ­role-playing in pairs, using vignettes typical of care work drawn
from interview examples.
After the workshop, I provided all staff with a leaflet of effective communication
tips and a lanyard card outlining the steps involved in the SHARE4CARE process.
Clinical leaders, enrolled nurses, and personal care workers of influence were tar-
geted to promote and coach colleagues in using the tool. Training also included infor-
mation on introducing Buzz meetings, which were the responsibility of the clinical
nurse manager and clinical leaders, supported by me. SHARE4CARE was imple-
mented immediately following the workshop, but only across morning and afternoon
shifts because of limited staffing.
Unfortunately, the delivery of the training workshop had been delayed, thus sig-
nificantly reducing the time available for implementation and evaluation, given the
strict completion timelines specified by the funding body. Contributing to the delay
were also changes of management at the Wisteria Gardens site and the absence of
the senior manager site liaison for six weeks, combined with two gastroenteritis out-
breaks and competing priorities for care staff training time. Consequently, the inter-
vention was implemented for only three of the planned six months.
Evaluation is a critical component of realisation to understand whether the inter-
vention was effective and how outcomes were achieved. Each week, I conducted
60 Ergonomic Insights

spontaneous ­5–10 minutes interviews with care staff and clinical leaders about expe-
riences from using the SHARE4CARE tool and participation in Buzz meetings.
Evaluation metrics included numbers of Buzz meetings, uptake of the tool, and rat-
ings of their effectiveness. After three months, interviews and surveys were repeated
to evaluate change. All staff interviewed were aware of Buzz meetings, although
only 40% had attended at least one because meetings had not been implemented for
some afternoon shifts or were held when individual staff were not on shift.
The interviews revealed that despite staff reporting workloads having intensi-
fied in one unit, improvements were made to equipment and teamwork, resulting
in reduced WMSDs risks. Staff perceived residents had become more dependent,
requiring greater teamwork to provide care. Following the commencement of the
new restraint policy, specific training was also provided on handling sensor mats and
using new equipment. During the intervention, large areas of carpeted flooring were
also removed, reducing forceful manual handling effort.
For psychological risks, staff reported greater support from supervisors and
managers, being listened to and consulted, and better ­co-operation. Carers reported
improvements in management support when responding to challenging behaviours
by residents or family members. C ­ o-operation, teamwork, and i­nformation-sharing
between clinical leaders and care staff had increased since Buzz meetings begun.
Participants attributed this to greater staff awareness, listening to each other, and
willingness to share information. Clinical leaders also observed improvements in
care delivery, planning, and documentation due to improved ­information-sharing.
The findings from the surveys showed modest improvements in physical and
mental fatigue and body part discomfort in the upper back and shoulders. Physical
work demands improved with reduced frequency of demands, though with the same
effort required. Mental demands remained similar, although qualitative comments
revealed less need to remember information, make a mental effort, and show emo-
tions inconsistent with those being felt. Job resources had a modest improvement,
most notably in being able to express emotions without negative consequences,
choosing how to do tasks, and being able to use skills and knowledge to solve com-
plex tasks. Engagement scores remained unchanged ­post-intervention, with modest
improvement for inspiration.
The most significant improvement was in the climate of psychological safety,
demonstrating perceived enactment of organisational policies, practices, and pro-
cedures to protect worker health and safety. ­Pre-intervention Wisteria Gardens PSC
score indicated a high risk for psychological injury and i­ll-health, which decreased
to moderate levels ­post-intervention. Staff feedback on the quality of communica-
tion during Buzz meetings also showed improvements in feeling energised, strong,
enthusiastic, inspired, and keen to go to work.

DESIGNED WITH CARE: SUCCESSES AND FAILURES

Our intervention, while implemented only for a short period, showed a modest posi-
tive impact on care staff risks for WMSD and psychological injury risk, achieving its
primary aim. We experienced measurable improvements in communication quality
and relationship satisfaction, which translated into tangible improvements in care
Opportunities and Challenges for Designing Quality Work 61

delivery, planning, and documentation. A significant success was the rapid improve-
ment in PSC for Wisteria Gardens; within three months, the increase in supervisory
support was instrumental in reducing the risk profile from high to moderate risk,
providing impetus for continued improvement.
The key to success in our intervention was the participative c­ o-design process, for
its value in bringing participants together with the common purpose of improving the
quality of work. The ­co-design process was a success and a failure at the same time,
given that the extent of participation was limited. Nonetheless, persistence, enthusi-
asm, and creative approaches to engagement achieved quality participation and were
the key to achieving positive workplace improvements.
Furthermore, successful outcomes of the DWC intervention were more readily
achievable because we used the job crafting model to guide the design and content
of the intervention and evaluation. The model was valuable in highlighting the range
of measures required to demonstrate and explain the holistic change and provided a
structure for describing the intervention to participants. It helped build participants’
confidence that the intervention was plausible and would be worthy of investing their
effort. Using mixed methods also contributed to demonstrating tangible improve-
ments, where qualitative data supplemented quantitative ratings to illustrate specific
examples of improved practice and experiences of more collaborative interactions.
On the other hand, the low engagement, commitment, and trust of senior manage-
ment were significant barriers to undertaking the intervention. Being an external
consultant, this manifested as limited access to the site for one day/­week, and always
having a Head Office liaison person on site. The result was low participation and
repeated delays to implementation. In the DWC project, half the number of staff
required were released to attend training, limiting exposure to, and uptake of the
intervention. To counter this, I invested heavily in building trust in relationships with
senior management at Head Office and Wisteria Gardens by engaging with them
regularly, checking in on current happenings, offering suggestions on strategies, and
providing information on successful interventions. I also maintained high visibility
with care staff through informal interactions during work time and breaks.
Likewise, I identified and met informally with individuals and small groups of
curious care staff, briefly explaining the intervention purpose, the SHARE4CARE
tool and Buzz meetings, engaging staff, and disseminating the intervention at the
grassroots level. A consequence of low participation was the small sample size for
surveys, interviews, and a low uptake of the SHARE4CARE training and tool use.
This meant that the results were not conclusive overall despite them being positive
and promising.

THE LESSONS LEARNED

Intervention research is dynamic, and predicting the course and outcomes of change
is challenging and surprising. The lessons learned from the DWC project may be
instructive for other work design interventions.
First, there is never an ideal time to implement change since there will always be
competing priorities. Respond to the immediate needs by starting small with one
change, in one workgroup if necessary. Use these experiences to build foundations
62 Ergonomic Insights

for pursuing more ambitious problems and opportunities. Build trust and embrace a
­co-design approach to gain commitment and learn from participants’ experiences.
Second, change can be achieved quickly when starting small, but sustainable
change takes sustained effort. Impart technical and social skills to others, especially
leaders and workers of influence, and work at achieving integration with other organ-
isational processes and priorities. Most importantly, be flexible and adaptive and sell
the merits of the intervention and value of work design.
Third, implementing successful organisational interventions requires ongoing
demonstrable commitment from senior and middle management. Their role is critical
in accessing staff, providing positive messaging, prioritising intervention activities,
and generating momentum. Hence, invest in achieving commitment at all levels of
the organisation. Adopting an organisational focus, even when working in a localised
group, maximises the potential for sustainability and success through integrating
changes in the organisation’s practices and culture. The facilitator must conscien-
tiously support management to lead the change, creating a symbiotic relationship of
mutual value. Sustaining outcomes requires maintenance of new behaviours after the
facilitator has left, so the support of senior management and workers of influence is
critical to success.
Fourth, we must build the evaluation into the intervention from the discovery
stage and throughout design and realisation. Using a model or theory to guide inter-
vention design and implementation helps explain the purpose and process to partici-
pants and promotes robust evaluation. Reactions to change can vary and may occur
quickly but not necessarily be sustained. Also, be mindful that social desirability
may influence reporting of change, where participants provide responses perceived
to be more acceptable to the facilitator or management.
Finally, an effective facilitator must maintain persistence and optimism, transmit-
ting it to intervention participants, catalysing enthusiasm and uptake. Effective plan-
ning is a key to guiding project success, but the facilitator must be prepared to adapt
and be flexible, given busy workplaces have competing priorities. Honouring the
­co-design process throughout project realisation will ensure activities are relevant,
expectations remain realistic, and p­ roblem-solving and review are ongoing, consis-
tent with the contract of engagement.

REFERENCES
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 6 When Success Is
Not Success, We
Strive to Do Better
Sara Pazell
ViVA health at work

CONTENTS
Manual Task Risk Management................................................................................66
Discovery Phase...................................................................................................66
Design Phase........................................................................................................ 67
Realisation Phase................................................................................................. 71
­Student-centred Curriculum Design......................................................................... 72
Discovery Phase................................................................................................... 74
Design Phase........................................................................................................ 74
Realisation Phase................................................................................................. 75
References................................................................................................................. 76

When someone asks me about what I do for a living, I hesitate. How can you quickly,
in a sound byte or a single phrase, translate the complexity of human factors and
ergonomics that draws upon environmental, engineering, psychology, social, organ-
isational, kinesiology, and exercise sciences? The design practices have health,
­well-being, and sustainability aspirations also. My answer may be simply,
Sara: “­I am a work design strategist. I help design work for health and productiv-
ity”. This is usually met with a quizzical response and a remark like,
Curious others: “­Oooohhhh. ­Uh-huh”. If the person dares to venture further, I
might be asked, “­So, do you work in human resources?”
Sara: “­Well, we can leverage the workforce strategy to inform design. We design
for diversity to help enact inclusivity policies, so the human resources business units
could have some of their objectives met by what we facilitate in work design”.
Curious others: “­Um, okay, so do you work in health and safety?”
Sara: “­Some ergonomists align their work in the domain of health and safety.
I prefer to anchor my work to design that can address health and safety concerns
with productivity, workforce strategy, well-being, employee engagement, procure-
ment, operations, engineering, sustainability, continuous improvement, facilities
management, technology adoption, and similar. In other words, work design strat-
egy extends and unites all business units, if permitted, with an overarching design
philosophy about human performance”.

DOI: 10.1201/9781003349976-6 65
66 Ergonomic Insights

Curious others: “­ Okay, so you mentioned work as an ergonomist, like

agriculture?”
Sara: “­Ah, almost. That is an agronomist, and sometimes it feels like we push
stuff uphill; this is true, but ergonomics is a unique discipline”.
Curious others: “­Oh! Ergonomics. So, you help people with their office worksta-
tion desks, chairs, and computers, right?”
Sara: “­Well, workstation ergonomics is one area of our work. Ergonomics and
human factors address how people think, socialise, move, act, interface with equip-
ment, and work productively and sustainably. We help design tools, equipment,
environments, and work systems across all industries, like mining, transportation,
finance, education, health, manufacturing, retail, government services, and, yes,
agriculture. Ergonomics is not a product, like an “­ergonomic mouse”, it is a design
practice”.
Curious others: “­Wow. Errr… how confusing”.
And so, it goes… When a discipline of work or a profession is poorly recognised
in industry, barriers can exist. A lack of familiarity about what someone does or how
they should think can lead to biases, misinterpreted expectations or assumptions,
and the imposition of and constraints about the agency and scope of work. If people
do not know what you do, how can they refer to your services or understand how to
let you advise per your knowledge base, versus limit you to a question that needs
answering per their world view?

MANUAL TASK RISK MANAGEMENT

Discovery Phase
I worked as an occupational health and ergonomics adviser while on a casual con-
tract with a large construction organisation. This case was housed in their road con-
struction and maintenance division. Ergonomics was new to the organisation, and
the teachings were in their infancy: Their programs were immature. I spent my days
observing operations and speaking with the staff to get to know them and better
understand their work. I ran workshops about manual task risk management, pro-
viding interactive education about work tolerances, task design, and risk factors of
musculoskeletal disorders. I also taught about general health systems and biopsy-
chosocial models of health, including what we can do to inspire health through good
nutrition, hydration, rest, social relations, and activity.
The workers in the field, who were, by and large, a male population, began to
acknowledge my keen interest in their work, not as an auditor, but as someone vested
in the design of work for their health and productivity. As such, they began to trust
me. They became accustomed to my presence and my questions and, I believe, looked
forward to some of our conversations. I was enthusiastic about my work. This was a
new world for me. One of my favourite aspects of ergonomics advising was learning
about how the world ticked, the mechanisation of industrialised societies, a field trip
with every outing to understand “­a day in the life of” a new neighbour. This intrigued
me and contributed to my youthful vigour in my profession, no matter my seasoning,
chronological age, or experience.
When Success Is not Success, We Strive to Do Better 67

Design Phase
After one such training delivery of manual task risk management for field and plant
mechanics, I encouraged participants to nominate tasks that could be more effi-
cient. I invited them to imagine their work and picture opportunities based on tasks
that were meaningful and important to them and the business. I asked them to envi-
sion what “­new” might look and would feel like could the task be ­re-designed and
unfettered by process or budget. We spoke about what they dreamed could hap-
pen, how it might be designed, and how that destiny could be shaped for ongoing
resilient performance. This was an appreciative approach to work design (­Bushe &
Kassam, 2005).
As fantastic as this sounds, believing that change is possible in what usually might
be a menial task enlivens work. A manual task may seem routine because of famil-
iarity, which can breed complacency, but once workers are given agency to become
­partners in designs (­­Burgess-Limerick, 2018), these daily tasks are made more mean-
ingful; they signify the importance of their work and how their imagination can be
applied. Being given a voice means that you and your ideas matter, and the work
design can better reflect the diverse needs of those who do those daily tasks (­Pazell,
2021). One of the tasks that they nominated for ­re-design was removing and replac-
ing paver wheels in preparation for tyre changes (­Pazell, 2018).
An ­asphalt-paving machine lays, forms, and partially compacts a layer of asphalt
on roadway surfaces. As with most e­ arth-moving construction equipment, it is a large
and heavy piece of machinery. In this case, the tyres used by the machinery mea-
sured 1,470 mm diameter and weighed 400 kg when ballasted and filled with water,
a common practice to stabilise heavy machinery tyres. Removing the wheels to pre-
pare for the tyre change was a ­three-person job. The tasks required equipment isola-
tion; chocking the wheels; removing bolts, the side arms, and adjusting hydraulics;
releasing the tyre and assembly to manoeuvre on forklift tynes; and forklift opera-
tion. The tyre was moved from the workshop to an outside storage area, and water
was released from the tyre. An outside contractor changed the tyre once the wheel
was set aside and emptied.
Once the wheels were chocked by blocks, one mechanic operated a forklift. There
were two other mechanics involved in the t­yre-changing task, and they used hand
tools such as rattle guns, spanners, sockets, breaker bars, crowbars, chains, and a
jack stand to remove the wheel (­­Figure 6.1). There were hazards in this work, and
the mechanics helped identify these: working near the mobile plant, pinch points,
and manual tasks with heavy aspects requiring extreme exertion and awkward body
postures. There were hand tools with vibration and noise exposures too. Hence, there
were risks of collision, compression injury, musculoskeletal disorder, and slips/­trips/­
falls. Some of the explosive risks were mitigated for these workers because of the
contracted work for removing and replacing the tyre. Cognitive distractions were
also common in the workshop area, arising from emergent service requests, espe-
cially related to breakdowns and other urgent work, or visitors from central offices,
suppliers, etc. Clutter in the workplace was not uncommon, such as scattered tools,
machinery, or equipment, especially when in proximity to colleagues working closely
on neighbouring tasks within the covered bay.
68 Ergonomic Insights

­FIGURE 6.1 Paver wheel removal inside the forklift tynes.

The seven mechanics, including their team leader, were encouraged to participate
in developing design concepts. I asked them to consider what they wanted to achieve
if the task could be done differently. They asked for a more efficient task; fewer work-
ers required to do the job; reduced risk for collision with the forklift, hand injuries,
and back discomfort; and general creation of ease so that this was not a bemoaned
task assignment.
Ironically, this was not the first time that this crew attempted to address the risks
of this task. They had previously identified the paver ­wheel-changing task as a hazard
on their reporting logs, but they felt that it had gotten nowhere and did not receive
support or feedback. The hazard log had not escalated into a risk assessment or any
further action, so they left it be, as work that simply needed doing. This, to me,
indicated a measure of trust and hope that, when they raised the issue through our
training forums, they believed that change might be possible.
I felt that this was achievable, mainly because of the workers’ commitment. It
was a ­well-defined task with repeatable steps and firm boundaries that might be
When Success Is not Success, We Strive to Do Better 69

reconstructed with the proper assistive devices. I raised the issue by speaking with a
regional contracting and line manager. I noted it on my monthly management report
also. I asked to escalate this for manual task risk assessment, which I was happy to
conduct and oversee. A meeting was held with the regional contract manager, the
capital equipment manager, and me. The capital equipment manager wanted to know
why the issue was being addressed and whether the task had been reported through
standard hazard reports previously. He was taken aback when it was explained that
the crew members’ requests had gone unnoticed for more than a year. The task and
related issues had been reported in hazard logs. It was flagged for quality improve-
ment on a register more than a year prior, but the requests had gone unnoticed.
Despite these conversations and reports, seven months transpired. The workers
remained inspired mostly because I checked on them regularly and continued to high-
light the outstanding issue on monthly reports received by state and regional man-
agement and central safety and operational support teams. The workers continued
to examine solutions, often on their own time, including attending a supplier ware-
house and other ­road-construction mechanical workshops. I partnered with them and
sent suggestions of wheel dollies from online research material and investigations of
those used in the mining industry. However, they explained that most were i­ ll-suited
because they could not fit within the narrow space of the wheel arch. This is impor-
tant: as ­co-designers, the workers are subject matter experts and, when involved, can
help determine task solutions that are likely to work (­­Burgess-Limerick, 2018).
Eventually, the workers found a potential solution, one used by the paver manu-
facturer, a unique wheel dolly that fit the wheel arch of the pavers in use. However,
line management denied their request for a product trial. This changed when the
­state-wide general manager directed the trial. This manager visited the depot and
heard directly from the maintenance crew. He learned about the task and listened
to their concerns. He confronted the line and capital equipment managers. The next
day, the workers advised me that they could be involved in the risk assessment with
me and, if warranted after the review of my report, trial new equipment and construct
meaningful change in the design of the task. However, that was coupled with a dress-
ing down. They received a severe warning from their line management that they were
not to speak about their management channels or go around their line of communi-
cation again. Apparently, this was prevalent in the culture in this work area, hence
their reluctance to advance the issue beyond what had been tried through reporting
registers. Had they actioned otherwise, there would be a risk of retribution, such
as unfavourable work assignments, constraints on promotions, or another dressing
down and ongoing conflict. However, the consequences were largely left unspoken.
The imagined penalties may have been worse than reality, but the threat hung in the
air, nonetheless.
I met with the crew again and conducted a biomechanical analysis to determine
the potential reduction of musculoskeletal disorder risk if a hypothetical trolley were
used. The crew contributed to this process. They clarified or corrected the assump-
tions that I made so that I could consider aspects like the exposure levels, movement
patterns, tool use, and weights. I watched them do the task, and they simulated sce-
narios for me, like when someone lost their grip during tyre manoeuvring. I took
images and recorded videos. I measured the reaches and examined the equipment.
70 Ergonomic Insights

I was advised to steer clear of the forklift because of the inherent dangers with the
risk of pedestrian contact or collision, and I was provided space to work outside the
restricted areas.
The workers were determined to change this task, yet they whispered if line man-
agement were nearby. Something shifted, and this task change became their state-
ment of rebellion. The risk assessment was conducted with ergonomic software1 to
consider the instrumental functional movement and biomechanical work demands,
such as exertion, exposure, posture, and repetition of movement elements. Elements
of pinch points, cognitive load, and work pace/­stress were also considered. The soft-
ware was chosen because it fulfilled the tenets of a risk assessment tool that was
appropriate for manual task injury prevention (­­Burgess-Limerick, 2003), including
the following:

• Suitability to a complete range of manual tasks.

• Capability to synthesise the assessment of a range of interacting factors that
are biomechanical, cognitive, and psychosocial in nature.
• Unique assessment of injury risk to all associated but independent body
regions.
• Comprehensive assessment of risk that incorporates the guidance about
threshold tolerances without false levels of presumed precision (­because
of the significant variability among humans, tissue capacity, and work
performance).
• Capable of determining risk factors that lead to acute and cumulative mus-
culoskeletal disorders
• Determination of the level of the relative severity of independent risk factors
per task exposure to inform design concepts and control strategies.
• Suitability for use by generalist safety and health teams should ­re-assessment
be required to contrast any changes to the design of the task following base-
line investigations (­­Burgess-Limerick, 2003).

The biomechanical risk ratings showed an extreme risk to the lower back and arms
and a high risk to the shoulders and legs, mainly owing to exertion and awkwardness
of postures. Also, there was the potential for cognitive distractions and perceived
time constraints, which can contribute to workload exertion and risk for musculo-
skeletal disorders (­Macdonald & Oakman, 2015). There were high cumulative risks
to the lower back and arms and moderate cumulative risks to the shoulders and legs,
owing to the combination of exposure levels, movement, exertion, and repetition. The
task occurred in an o­ pen-air, sheltered workshop, so weather conditions could also
factor into the risk considerations. This workshop was in the subtropics, so heat and
humidity could add to fatigue. However, winter was cool to cold, which can add to
reduced circulation, either circumstance a factor in musculoskeletal disorder risks
(­­Burgess-Limerick, 2003).
If a suitable trolley were used, and the forklift was no longer needed, these risks
would be significantly reduced by 80% in the back and arms for acute risk reduction

1 https://­www.ergoanalyst.com/
When Success Is not Success, We Strive to Do Better 71

and more than 69% for the arms and back for cumulative risks. Also, productivity
would improve because of the ­re-assignment of the forklift operator to other tasks
and the expedience at which a wheel could be removed and manoeuvred within the
workshop, an estimated savings of ­two-person hours each time the task was done
(­removing and replacing the wheel). This information was reported and reviewed
through appropriate channels, including the regional and state management, and the
trolley trial was approved.

Realisation Phase
The workers procured a trolley for trial, per the advice from the paver manufacturer
(­­Figure 6.2). They trialled it and loved it. The crew told me about their satisfaction.
They met their design objectives: the new trolley saved time, added efficiency, and
moved them out of harm’s way of mobile plant and from heavy lifting. Leveraging
this success, another workshop within another region of the state purchased the same
trolley. The project was celebrated among our crew, yet the team leader was affected,
and so was his team. He started searching for a new job. He had been blamed for
being somewhat of a “­­rebel-rouser” because of his passion for this project and his
voice when speaking to senior management, above the line management, who ini-
tially refused his efforts. The others were sullen and uncertain of their future while
working with the manager, who was in line for a promotion. The project was lauded
by the state general manager, shared in an industry conference paper, and celebrated
by way of communication in a national company newsletter. Notably, the line and
capital equipment managers were credited with the project’s success, and it was their
photos displayed in the newsletter, taken with the new paver wheel trolley.

­FIGURE 6.2 A wheel trolley that eliminates forklift use.

72 Ergonomic Insights

The project was successful if evaluated by its design objectives to reduce the
risk of fatality or injury and add to productive, efficient work solutions for quality
improvement. However, if measured by the effect on team morale, it had gone south.
­Post-rebellion satisfaction was ­short-lived because the reality of their job design and
reporting lines meant that the workers felt less enthusiastic about making a positive
change again. They were demoralised. The egos and perceived threats by manage-
ment were discomfiting, and they wondered how they could be inspired to innovate
or adapt tasks to improve design again. This is what I learned:

• Ergonomics workshops and training can inspire workers to consider task

­re-design, either for new tasks or those that had been reported as hazardous
but never actioned. The training can invigorate workers to act.
• Shared ­problem-solving, like that which can occur through task ­re-design,
is a hallmark of adult learning.
• Manual tasks represent the fabric of daily life for field workers; taking an
interest in what they do and how they work is essential to their engagement.
• Consulting workers is in line with legislation in several countries, and par-
ticipative ergonomics projects discharge the obligation of the duty holder
(­WHS Act, 2011). However, the involvement of workers should be sought in
genuine and supportive ways, not just to meet compliance standards.
• Line management might resist change, even though there may be support
from those above them and the field staff. Involving the line management as
change agents is vital to success. Somehow, this must be done.
• Ego is dangerous if it impedes changes to safety and productivity.
• As an advisor, one’s efforts are restricted to influence rather than command.
It is difficult to be supportive when observing ­head-shaking poor manage-
ment practices. It would be interesting to know what business would look
like if work design strategists, with human factors and ergonomics train-
ing and ethos, were elevated as ­decision-makers with more power to effect
change.

­STUDENT-CENTRED CURRICULUM DESIGN

I am fortunate to consolidate and extend my learning in human factors and ergo-
nomics through ongoing teaching and research activities with several universities.
Dipping my toes in the proverbial waters of education helps me apply a framework to
my consultancy that is supported by evidence. It continually challenges me to extend
my thinking or, when teaching, to explain the art and science of ­human-centred, good
work design in digestible terms so that it is better understood. In this case, the ben-
efits of my professional work were applied inward. That is, I had the chance to work
with a colleague2 and use human factors approaches to address the curriculum design

2 I extend my gratitude to my colleague, Dr Anita Hamilton, with whom I enjoy my work and from whom
I have learned a great deal. I acknowledge Dr Hamilton’s contribution to this course ­re-design and the
journal paper that we wrote to describe the experience in academic literature.
When Success Is not Success, We Strive to Do Better 73

of an undergraduate occupational therapy course. This meant that a ­student-centred

process of the course design was embraced at a university level of education.
Luckily, I worked with a colleague who was welcoming of change and new tech-
nologies. Continual improvement is part of her ethos. We ­co-taught this university
course and often shared ideas about teaching innovations or content specialties.
This was a unique course: students were asked to learn about psychometric tools for
standardised assessment, pretend that they were a client newly diagnosed with mul-
tiple sclerosis, and, conversely, act as a therapist evaluating their c­ lass-partner when
they ­role-played their experience with multiple sclerosis (­­Figure 6.3). The students
assessed different performance aspects weekly, presented their findings in mock case
conferences, and presented formally to their professional peers when describing the
assessment tool that they were selected to study in detail. There were weekly quiz-
zes, and the course was offered as a “­­flipped-classroom”, with online learnings and
content engagement expected of students before the ­in-session facilitated tutorials
(­Cobb, 2016).
While these educational aspects are well in line with the professional role expecta-
tions of an occupational therapist, they were new to these ­second-year undergraduate
students. When students struggled with the elements of clinical assessment, role play,
or formal presentations, we wondered what could be done to elevate their learnings
and shift anxiety into constructive learning. There were coaching tips that we could
provide during the course delivery. Still, once a university curriculum is approved
and implemented, a formal process must be undertaken to redesign the course. A
new outline must receive central approval, ensuring that the changes meet accredi-
tation standards and guidelines as a measure of quality control. We committed to

­FIGURE 6.3 Occupational therapy students as mock clients and mock therapists.
74 Ergonomic Insights

reviewing the course formally for the next offering and learning from our teaching
and the student experience.

Discovery Phase
A human factors approach to competency (­Zupanc et al., 2015) and curriculum devel-
opment (­Pazell & Hamilton, 2020) was undertaken. We decided to learn from the
student experience and invited past student involvement in the course r­ e-design con-
siderations. While these students were entering their third year of study, a busy term
peppered by fieldwork experiences, we managed to attract a focus group of six. These
students acted as intermediaries to explain our conversations and represent the needs
of more than 40 of their ­student–colleagues who otherwise had difficulty juggling their
schedules to attend our meetings. Since occupational therapy is a course grounded in
­client-centred construction of health and systems theories of ­person–­place–­activity–
performance (­Baum, Christiansen, & Bass, 2015), involving students to c­o-create
improved educational models was welcomed by my colleague and the students.
Compatible with this ideology, we dissected the students’ roles in this course. We
identified six student roles: a generalist student, a mock client, a mock therapist, an
evaluator of standardised assessment tools, a clinical documenter, and a case confer-
ence presenter. Each of these roles was dissected into nine cognitive components to
frame the requirements: knowledge, skills, abilities, tactics, ­decision-making, situ-
ation awareness, heuristics, interpersonal skills, and intrapersonal skills (­Pazell &
Hamilton, 2020). Through course curriculum review; s­ emi-structured and informal
interviews and focus group meetings with students; review of assessment perfor-
mance, especially the outliers (­i.e. the work of past students who struggled, and that
of those who excelled); and discussion with colleagues about the course expectations,
91 elements were identified within these components. That is, 91 aspects that we
could influence or prop through course design and teaching leadership.

Design Phase
In the “­generalist student” role, a student was expected to exhibit competence in the
computer interface with the learning management system to engage with content
before tutorials. We elected to focus on providing more ­early-stage assistance and
­Web-based video instructional aids. We did not want the computer interface acting
as a primary stumbling block to learning key content. While computer literacy was
considered an essential professional skill to acquire, it was not one that they had to
achieve solo. In their “­mock therapist” role, they needed to learn how to create defen-
sible daily and s­ ummary-based clinical case notes. We emphasised their training and
gave detailed ­scenario-based examples and tutorial content to develop these weekly.
The ­student-advisors suggested less formal assessment of case conferences. While
we struggled with letting this go, since case management skillsets are vital profes-
sionally, we negotiated ­trade-offs, like converting case conferences into weekly tuto-
rial practice sessions without formal assessment. We worked with our colleagues in
other courses to consolidate the case conference teachings and formalise the assess-
ment in subsequent years.
When Success Is not Success, We Strive to Do Better 75

Another interesting finding was the students’ difficulty in conducting home and
workplace assessments, constrained by time and the lack of understanding about what
clinical symptoms to profile in different environments when acting as a mock client.
Two changes arose. First, we converted the ­partner-based home assessment require-
ment to a simulated immersive environment using 360° camera technology that could
be viewed either as a video or as an interactive experience using a headset. My col-
league and I recorded four h­ ome-based and four w ­ ork-based experiences so that they
were standardised, and we knew what to expect and how to coach students. We punc-
tuated these visual experiences with some narration and notation to explain environ-
mental aspects, like trip hazards or narrow spaces to navigate in the home. This was
designed to help the students in client and therapist roles to prompt their exhibition
of symptoms or assessment focus. Second, we helped the mock client by creating a
symptom list on small mixed and matched cards. In each tutorial, a student could select
some random symptoms to help them formulate their presentation, which became the
challenge for their mock therapist s­ tudent-partner: to determine what symptoms were
on display and how this affected the mock client’s functional presentation.
Their contribution to the curriculum design impassioned the ­student-advisors. So
much so, they agreed to be videoed to provide their “­pearls of wisdom” when asked
by my colleague to do so. These videos were played during tutorial sessions and acted
as ongoing p­ eer-based coaching support for students when the course ran in the subse-
quent term. A couple of the s­ tudent-advisors agreed to come into the tutorial sessions
to spend some solo time with the new students. They provided candid insights and
advice about how to get through the course.

Realisation Phase
I learned a lot during this course ­re-design. No matter the wisdom or fresh insights
I believe that I can lend to a situation, I am one voice. The role of the human factors
professional is exceptional when allowed to be a catalyst for change, and when ­subject
matter experts, those most affected by the design change, partake in the process as
design partners Notwithstanding, in the workplace, these methods discharge the obli-
gation of the duty holder and show compliance with workplace legislation in Australia
and elsewhere (­WHS Act, 2011). Good course design can boost student satisfaction
(­Lee, 2014). Also, accreditation standards exist in some programs, like in Occupational
Therapy (­OT Council of Australia, 2018), which suggest that “­students have opportu-
nities to be represented within the deliberative and d­ ecision-making processes of the
program” (­­p. 8). This was supportive of the c­ o-design methods that were undertaken.
Innovation is possible if the milieu is right, unfettered by management who
say “­ no” to the methods, and inspired by colleagues who share the vision of
­co-constructing new ways of working. Friendships were formed, and others consoli-
dated during this course redesign process, including ongoing positive relations with
the ­student-advisors who are now graduates and working professionals. With ego
set aside, change was made possible through an uncomplicated process, and posi-
tive feedback was associated with the adaptations. This made it a successful case.
Tackling an entire university programme in such a way would be novel and, likely,
harder to sway given the influence required of more d­ ecision-makers, but, as with
76 Ergonomic Insights

most ergonomic changes, small wins pave the way for instrumental change and sys-
tem ­re-design. Some of the students involved as advisors or participants in the new
programme could very well be those who direct more of the s­ ystem-wide revolutions
in the design of the work that awaits them. It shall soon befall them to advance win-
ning approaches representative of a ­human-centred organisation (­ISO 27500:2016).

REFERENCES
Work Health and Safety Act. (­ Austl). (­2011). https://­www.legislation.gov.au/­Details/
­C2018C00293
Baum, C. M., Christiansen, C. H., & Bass, J. D. (­2015). The Person-Environment-Occupation-
Performance (­PEOP) model. In C. H. Christiansen, C. M. Baum, & J. D. Bass (­Eds.),
Occupational therapy: Performance, participation, and well-being (­4th ed., p­p. 49–56).
Thorofare, NJ: SLACK Incorporated.
Burgess-Limerick, R. (­2003). Issues associated with force and weight limits and associated
threshold limit values in the physical handling work environment: Issues paper commis-
sioned by NOHSC for the review of the National Standard and Code of Practice on Manual
Handling and Associated Documents. http://­burgess-limerick.com/­download/­d2.pdf
Burgess-Limerick, R. (­2018). Participatory ergonomics: Evidence and implementation les-
sons. Applied Ergonomics, 68, 289–293. DOI: 10.1016/­j.apergo.2017.12.009
Bushe, G. R., & Kassam, A. F. (­2005). When is appreciative inquiry transformational? A
meta-case analysis. The Journal of Applied Behavioural Science, 41(­2), 161–181. DOI:
10.1177/­0021886304270337
Cobb, W. N. W. (­2016). Turning the classroom upside down: Experimenting with the flipped
classroom in American government. Journal of Political Science Education, 12(­1),
1–14. DOI: 10.1080/­15512169.2015.1063437
ISO. (­ 2016). ISO Standard 27500:2016: Human-Centred Organisations. International
Standards Organisation.
Lee, J. (­2014). An exploratory study of effective online learning: Assessing satisfaction levels
of graduate students of mathematics education associated with human and design fac-
tors of an online course. The International Review of Research in Open and Distance
Learning, 15(­1), 111–132. DOI: 10.19173/­irrodl.v15i1.1638
Macdonald, W., & Oakman, J. (­2015). Requirements for more effective prevention of work-
related musculoskeletal disorders. BMC Musculoskeletal Disorders, 16, 293. DOI:
10.1186/­s12891-015-0750-8
Occupational Therapy Council of Australia Ltd (­the OTC). (­Dec 2018). Accreditation stan-
dards for Australian entry-level occupational therapy education programs. The OTC.
https://­www.occupationaltherapyboard.gov.au/­Accreditation.aspx
Pazell, S. (­2018). Good work design: Strategies to embed human-centred design in organisa-
tions. [Doctoral dissertation: University of Queensland]. Sustainable Minerals Institute.
https://­espace.library.uq.edu.au/­view/­UQ:3e5556a
Pazell, S. (­2021). Design for workplace diversity: A human-centred approach. ViVA health at
work. https://­vivahealthgroup.com.au/­ergonomics-resources/
Pazell, S., & Hamilton, H. (­2020). A student-centred approach to undergraduate course design
in occupational therapy. Higher Education Research & Development, 40(­7), 1497–1514.
DOI: 10.1080/­07294360.2020.1818697
Zupanc, C. M., Burgess-Limerick, R., Hill, A., Riek, S., Wallis, G. M., Plooy, A. M., Horswill,
M. S., Watson, M. O., & Hewett, D. G. (­2015). A competency framework for colonos-
copy training derived from cognitive task analysis techniques and expert review. BMC
Medical Education, 15(­216), 1–11. DOI: 10.1186/­s12909-015-0494-z
 7 Reshaping Lifestyle
Changes in a Heavy
Weight World
Keith Johnson
Fulton Hogan

CONTENTS
The Journey to Success.............................................................................................80
Remedies at the Specific Mine Site......................................................................80
The Author’s Journey........................................................................................... 81
Recruitment and Onboarding.......................................................................... 81
Systems and Processes.................................................................................... 81
Workplace Initiatives....................................................................................... 82
Health Management Plan................................................................................ 83
Anthromechanics in Equipment Design..........................................................84
Performance Management............................................................................... 85
Legal Position.................................................................................................. 85
Conclusion................................................................................................................ 87
References................................................................................................................. 88

Several years ago, I worked at an open cast coal mine as a safety and compliance
superintendent. The average age of the workforce was between the ­mid-30s and 40s
with very minimal turnover. The mine was close to a local town where most of the
miners lived. The nature of mining is a sedentary job generally. The bulk of mining
operations relates to operating a mobile plant (­e.g. excavators, bulldozers, trucks)
whilst also being seated for the task. This, in combination with a lack of activities
outside of work due to long working hours at the mine and general poor health due to
genetics and lifestyle choices (­Suckling, 2017), led to a proportion of the workforce
being overweight or obese.
As such, part of the workforce became too heavy for some of the truck seats in a
specific type of mine haul truck. The standard seat of the truck had a ­weight-tolerance
rating of 120 kg. The workforce complained that the trucks’ seats would bottom out
when going over bumps on the haul road, even with the gas struts in the seat set at
maximum level. Several incidents were reported on site relating to seats bottom-
ing out, with initial causation thought to be related to the poor design or mainte-
nance of seats. However, postincident reviews (­e.g. vehicle seat servicing history, seat
functionality, road surface compliance conditions, and review of operator training

DOI: 10.1201/9781003349976-7 77
78 Ergonomic Insights

records) suggested that the seats and systems were compliant. Furthermore, the anal-
ysis of demographic data from the incidents suggested that the latter mainly involved
overweight or obese workers.
Back then, we contemplated that there were only two alternatives to dealing with
this problem. The first option, from a system design perspective, would be to replace
all ­120-kg ­weight-tolerance rated seats with ­200-kg ones across the whole fleet to
accommodate the overweight workers. However, the cost to swap out the seats would
be quite high. The prices for the seat itself started from $3,000.00 per item, depend-
ing on country of purchase with exchange rate and subsequent freight costs. This
cost excluded the necessary labour costs for removal of the old seat and installation
of the new seat, the downtime of the machine and potentially not being able to sell
the old seats and having to store them. From a reasonably practicable perspective, the
company initially contemplated that the seat replacement cost was ‘­grossly dispro-
portionate to the risk’ (­Safe Work Australia, 2011).
The second alternative was to terminate the overweight workers’ employment
because they could not meet the inherent requirements of the job. This option was
quickly dismissed. Apart from ethical reasons related to first exploring other alter-
natives, the workforce came from a ­close-knit local town and the site was heavily
unionised. Hence, taking that stance may have ended in strike movement by the
union. The latter would subsequently incur costs arising from potential wrongful
dismissal claims and/­or breaches of industrial relations legislation of Enterprise
Bargaining Agreements for the employer. This could be coupled with reputational
risk of community backlash against the company.
Indeed, there were also weight loss and general health initiatives we could con-
sider. However, these were not thoroughly researched or challenged as an alternative
due to the combination of the following factors:

• My general lack of understanding of the science behind such initiatives.

• Lack of openly accessible research on the outcomes of health initiatives.
• The cost to implement such an initiative. The employer should allocate funds
to secure support for workers by nutritionists, medical doctors, dieticians,
and/­or gym memberships. This kind of support is quite costly and would
generally occur offsite due to the lack of i­ n-house company resources. Over
time, and with regular appointments per employee, such an initiative would
lead to thousands of dollars expenditure per employee.
• The time lag between the implementation of health initiatives and actual
results for the overweight workers. This would have been several months,
and because the overall success of such an initiative was not guaranteed, it
could have been an overwhelming failure.

After general consultation with the workers and management team and some heavy
influence from union representatives, it was determined to proceed with the first
option above but only for the newest fleet. The reasoning was that the remainder of
the fleet was ageing and close to its e­ nd-­of-lifecycle, and the seat replacement was
cost prohibitive. On the other hand, the newer fleet had a much longer life expec-
tancy, which made the purchase commercially viable to accommodate those in the
Reshaping Lifestyle Changes 79

heavier weight range. Thus, the replacement of the 1­ 20-kg ­weight-tolerance rated
seats with ones having a safety ­weight-tolerance rating of 200 kg would expectedly
fix the problem of our overweight workers bottoming out on truck seats. This deci-
sion made sense at the time, because it seemed like a good engineering solution and
aligned with the concept of the ­well-known hierarchy of risk controls.
Hence, the site had managed the risk and would not ask workers to operate any
machinery without enjoying adequate safety levels. At the same time, the decision
was the path of least resistance as it was also supported by the mine’s workforce and
union interventions. Moreover, this option had been successfully employed at an asso-
ciated mine site, so it was deemed to be aligned with ‘­standard practice’. Surprisingly,
though, whilst the replacement of seats fixed the immediate d­ esign-related issue of
seats bottoming out and subsequent injury risk to the truck operators, it led to more
complicated issues.
First, the workers didn’t seem to implement anything at a personal level to reduce
or manage their weight. Either their weight remained the same, or they became
heavier because of their sedentary work coupled with long shifts and limited access
to and knowledge about healthier meal options. Furthermore, the workers did not
have any w ­ ork-related incentives to lose weight, especially after the new seats accom-
modated heavier operators. Based on anecdotal workplace conversations, the work-
ers felt there was no reason to abstain from the consumption of unnecessary calories.
Second, the workers that exceeded the 120 kg weight rating could now only drive
the trucks with the 200 kg seats. Since the trucks with the newer seats were the most
recent in the fleet and had better cab operating facilities, this created a logistical chal-
lenge and inequity among fleet allocation. Workers under 120 kg felt marginalised
from the newest fleet by workers that could only drive the trucks with 200 kg seats
because of the company’s new rules and, in hindsight, lack of distributive justice.
Simply put, lighter workers could only drive trucks that had seats with a maximum
rating of 120 kg, those trucks being the older ones in the fleet.
Third, the mine rescue team encountered further complexities. If a worker had
a medical issue (­e.g. a heart attack) or another emergency in/­on a truck with 200 kg
seats, trying to extricate the worker safely without any injury to the worker or the
mine rescue team became complicated and risky. Moving an extra heavy worker
from a cab that was a minimum of 4 m from ground level created manual handling
risks for the rescue team, and health and safety risks in general. The exertion aris-
ing from heavy and uneven (­human) loads could result in musculoskeletal disorders,
and there was a risk of falls whilst carrying a person from a high cab to the ground.
Fourth, as workers exceeding 120 kg could only drive one type of truck, the scope of
the mine to c­ ross-train these workers in other machines and activities (­e.g. dozer or
grader operator) was limited because this other type of machinery generally had a
seated weight rating of only 120 kg.
Consequently, whilst the uprated seats fixed the issue from an engineering per-
spective, the measure had no impact on workers’ health and generated unintentional
side effects. Thus, with the benefit of hindsight, replacing the seats was a poor call
and should not have been undertaken. It seemed a good idea at the time, but in long
term was counterproductive for the workforce and the company and set a poor stan-
dard for future risk management strategies and as a general benchmark for best
80 Ergonomic Insights

practice in the wider industry. On reflection, I attribute all the above to the fact that
the uprating of the seats was not based on a systematic and collective risk or change
management approach and a ­well-thought plan. The decision was mainly the result of
influences from external stakeholders, ignorance by a poorly informed safety depart-
ment, including myself, and the pressures on the employer to act the soonest possible.

THE JOURNEY TO SUCCESS

After realising the complexity of safe seating weight tolerances, we introduced rem-
edies to better manage overweight workers and the situation overall through bet-
ter system design per our understanding of the concept of total worker health, as
presented in more detail below. The other side of success regards my professional
journey since then. It is now based on research, study, and r­eal-world experiences
during which I have been able to develop, implement, and make ­better-informed
decisions. The part elaborating this journey includes the various steps involved in
better supporting overweight workers, starting from the recruitment and onboarding
systems and processes, including a Health Management Plan, continuing with per-
formance management, workplace initiatives, anthromechanics in equipment design,
and concluding with the legal position about where/­when an overweight worker may
be dismissed from the business.

Remedies at the Specific Mine Site

The first remedy adopted to ensure improvement for both the workers and the
employer was that the mining trucks with uprated seats remained on site for some
time and were later sent to a mine site in another country. No other seats on the
site were uprated beyond the manufacturer’s specification on the original seat. This
demonstrated equality across all workers because all seat weight ranges remained
the same across the fleet. More importantly, it set a minimum standard or a ‘­one size
fits all’ approach where design changes would not be made to accommodate those
who could not meet the minimum standard. Indeed, this does not reflect equity
where the work system serves the needs and characteristics of diverse workers and
supports those most marginalised. However, in conjunction with the other measures
and initiatives explained below and from a pragmatic perspective, equality or equal
access to the seating types in truck fleets was deemed the most feasible approach
back then.
Second, in consultation with the workforce, procedures were also developed and
discussed about what the new company standard would be for body weights and
access to trucks and other equipment. Any worker that remained excessively heavy
was provided with new strategies and requirements. If a worker’s weight was above
the seat rating, the worker was stood down from that substantive role and deployed
to another area of the business, on some form of suitable duties, which was agreed
between a medical provider, the employer, and the employee. Admittedly, the suitable
duties roles were difficult to effect because, generally, the tasks were not meaningful,
or inspiring, or had a short working window and included tasks such as photocopy-
ing, filing, or ­in-house training. However, this was only a first temporary step of
Reshaping Lifestyle Changes 81

the whole support programme. Additionally, the worker was placed onto a Health
Management Plan, provided with five free consultations with a nutritionist, and given
subsidised access to the local gym.
Furthermore, during the recruitment process, candidates were advised of the
weight ranges of the equipment regarding seat weight ranges for all plant and equip-
ment. This formed part of the ­pre-employment medical screening. Also, induction
training included better explanation of weight restrictions for equipment whereby the
pragmatic design specifications were explained so that workers understood the esca-
lation of their risks of developing musculoskeletal disorders and exposure to whole
body vibrations if their weight exceeded the seating design tolerances. In parallel,
the company launched a healthy eating campaign to raise workers’ awareness. To
support this, the workers were provided with subsidised health subscriptions, fruit
platters, and other healthy refreshments which were placed into the lunchrooms. As
an employer, we wanted to provide environmental conditions that supported good
nutritional choices (­Cohen and Farley, 2008).
The outcome was that six overweight workers got under the maximum weight
over the course of two to six months. Moreover, due to the matter being a topical
issue and a regular subject of conversation in the workplace, awareness was also
heightened.

The Author’s Journey

Recruitment and Onboarding
The first key aspect I have pursued in the management of overweight workers is to
identify them during the recruitment process and before they enter the company.
Undertaking a robust ­pre-employment medical examination is critical and can be as
simple as a health questionnaire that identifies a candidate’s health and eating habits
and weighing the applicant on scales to calculate their body mass index (­BMI). This
index helps to determine a person’s healthy weight range for his/­her height (­The
Heart Foundation, 2018). Depending on the person’s weight, the identification that
the job candidate could be a risk to the company can be and has been a catalyst in
offering or not employment (­e.g. concerns about climbing stairs, bottoming out seats
on equipment on rough roads, or inability to manoeuvre in confined spaces).
A precondition to the ­pre-employment medical assessment is the employer hav-
ing a solid understanding of the equipment used in the business that has a weight
safety rating. This can include items such as weight ratings for seats based on the
recommendations of manufacturers (­e.g. office chairs, and vehicle seats), portable
and mobile ladders, and safety harnesses for working at height. The company main-
tains an updated list of all equipment with their weight limits that we provide to the
­pre-employment medical provider. This way, the latter becomes aware of the suitable
weight range for specific jobs.

Systems and Processes

I have found it critically important that the company should also have robust systems
in place in the form of policies and procedures for the minimum standard and expec-
tations for workers’ health related to their weight during their employment. Workers
82 Ergonomic Insights

should also be supplied with a job description that outlines their legal obligations
and duties in the workplace to take reasonable care for their health and safety to the
extent this is possible and under their control. Another element around policies and
procedures is the frontloading and education of frontline staff. The consideration of
overweight workers might not necessarily be at the front of the mind for frontline
leaders. However, those persons should know specific elements, including definitions
of the terms ‘­overweight’ and ‘­obesity’, implications of having overweight and obese
workers in the workplace, management of overweight and obese workers, and subse-
quent legal obligations and ­pre-employment considerations.

Workplace Initiatives
There are varying workplace initiatives to assist workers to maintain good eating
practices or access resources that encourage healthy eating habits. One possible prob-
lem is when managers do not have a comprehensive understanding of how work can
impact a workers’ diet. This can be as simple as understanding the working environ-
ment. According to Pro Choice Safety Gear (­2016), diet issues for workers relate
to time pressures to get the job done; constantly changing worksites, as it typically
happens in the construction industry; or limited availability of food due to a lack of
lunchrooms, refrigerators, etc. Because workers can be hungry, tired, and ­time-poor,
it is easy to default to vending machines and food vans, because it is ‘­food to go’.
In recent years, I have sought to influence good eating practices ­on-site through
offering nutritional food and fruit bowls; providing access to lunchrooms/­crib huts
with microwaves and refrigerators to assist with ­pre-prepared healthier meals; pro-
viding skim milk instead of full cream milk and artificial sweeteners instead of
sugar; and using a food environment audit tool (­Griffith University, 2016) to better
determine the eating habits of the worksite. Improving food choices and amenities in
the work environment can lead to healthy eating becoming an extension of the work
organisation (­Lavallière et al., 2012)!
Furthermore, when looking for a minimum standard for implementing a weight
loss initiative programme, I have used the baseline assessment based on the ‘­Healthy
Workplace Framework and Model’ (­World Health Organisation, 2010). This frame-
work covers eight steps from mobilising and assessment through to planning and
acting, and then reviews and improves. It can be used in any health initiative ­roll-out
but is instrumental in the foundation requirements of ­Plan-­Do-­Check-Act for a suc-
cessful weight loss programme.
For an ­in-house weight loss programme, I have implemented the Mediterranean
weight loss programme (­Martin et al., 2019). This is a ­12-week programme to assist
in reducing body fat, and it is prefaced with a food frequency health questionnaire
and information sessions. The programme includes promotional awareness about
healthy eating and personal obesity risks, and it focuses on healthy foods such as
high intakes of fruits, legumes, whole grains, nuts and fish, and low intakes of dairy,
red meats, and alcohol. However, when I implemented this programme, it was only
effective for those that stayed for the whole 1­ 2-week course. Unfortunately, such
programmes can have a high dropout rate due to several reasons such as a lack of
motivation, the initiative not being suitable for the worker or the worker not being
able to adapt to the suggested lifestyle change.
Reshaping Lifestyle Changes 83

Other ‘­blanket’ weight loss and healthy eating initiatives I have implemented or
managed over time with reasonable success include the following:

• Healthy snacks and drinks in vending machines. Whilst the traditional

options are still available, healthy snacks provide variety and more options.
• ­On-site health assessments that include the assessment of weight and BMI
on a voluntary participation basis.
• Training sessions conducted by nutritionists and dieticians that speak about
(­un)­healthy eating and practices that can frontload the workers with scien-
tific and ­research-based information.
• Nutritional information posters in lunchrooms/­cafeterias.
• ­On-site exercise facilities. This is more applicable to larger projects and
remote sites with camp accommodation.
• Discounts or waived fees for gym memberships.
• Diabetes prevention programmes.

Health Management Plan

When a worker has been identified as being overweight and not meeting the inherent
requirements of their role, in consultation with human resources/­employee relations
staff, my process has been to hold an initial conversation with the worker to discuss
my concerns and offer the opportunity to the employee to respond. Where a mutual
agreement is met and the worker has agreed to lose weight, he/­she is then placed onto
a Health Management Plan (­Leighton Mining, 2009).
The Health Management Plan includes employee and employer information (­e.g.
names and contact details) and continues with the Action Plan. The latter is the
key part of the plan as it relates to the weight goals agreed (­e.g. the target weight to
be lost by specific date/­s) as well as the support services required. Those services
might include access to a dietician and/­or a nutritionist to assist the worker with a
menu plan and fitness goals and access to fitness facilities such as a gym or per-
sonal trainer if that’s what makes sense to the employee. What I have experienced
is that whilst the company may be paying for the nutritionist or dietician, due to
privacy reasons, the nutritionist or dietician may not share information/­reports with
the employer. Therefore, such information needs to be obtained from the worker,
where possible.
All these added services generally come with a cost; hence, this needs to be a con-
sideration for the company as well. I have had examples where the worker has failed
to achieve the necessary weight loss whilst accessing such services, meaning that
partly those cases could be seen as wasted effort and investment. Where this occurs,
employees must have regular catch ups with their nominated nutritionist/­dietician
to continually monitor and review their progress, their barriers, and whether they
remain aligned to the plan, and then determine the best method to get back on track
and towards a successful outcome. The final component of the Health Management
Plan is the approvals section where the employee and other stakeholders and per-
sons involved (­e.g. manager, medical professional, injury manager) sign the docu-
ments. This means the plan has been read by each stakeholder and is agreed upon
and endorsed.
84 Ergonomic Insights

Nevertheless, it is important to note that the initial conversation can be quite

daunting for the worker because they are generally told they cannot undertake their
normal role anymore (­e.g. truck or grader operator) and must assume another role.
The latter can be something they do not want to do and could be as menial as filing or
photocopying. The worker can also become wary about having their employment ter-
minated, and the employee can ask for clarity on this topic. The rest of the workforce
can also see what is occurring with the specific worker as he/­she is absent from their
normal place of work. Thus, this can add to the worker’s humiliation of being stood
down from their normal role. It is just as important to consider the worker’s mental
health during the Health Management Plan process, which is generally coupled with
the company’s mental health and ­well-being programme and Employee Assistance
Program. The latter is available to the employee as a free counselling service pro-
vided by the employer and is confidential.

Anthromechanics in Equipment Design

Another matter for consideration with aiding overweight workers is through equip-
ment design that the worker uses and can be reviewed through the research of
anthromechanics. Kumar (­2008) suggests that anthromechanics is the connec-
tion between anthropometrics (­i.e. measurements and capabilities of the human
body) and mechanics, with the research investigating the concerns of mechanical
design and fit as it relates to anthropometrics. Interior car design is an example
of anthromechanics, whereby the vehicle’s interior is designed to meet the needs
of the greater population and not a limited quota, and the ergonomic goal is to
design a product or system comparable to the needs and limitations of the end user
(­K roemer, 2007).
Vehicle manufacturers design the interiors of their vehicles (­e.g. foot pedals, arm-
rests) to accommodate anthromechancial concerns (­Bansal et al., 2009). Some car
manufacturers have developed an ‘­aging suit’ so designers have an understanding of
the impacts of aging when operating a vehicle (­Pultarova, 2016). The aging suit is
worn over the body (­like an outer metallic skeletal suit) and mimics health concerns
linked to aging such as vision impairment and loss of movement range or flexibility.
A similar suit could be developed that mimics overweight users so that car manufac-
turers could consider these anthropometrics in car design (­e.g. the positions of the
foot pedals or steering columns that are adjustable for volume).
Another example of anthromechanics is designing seat belts for overweight peo-
ple. Research conducted by the University of Virginia (­2019) suggests that thicker
fat around the belly and waist inhibits a seat belt suitably grasping the pelvic region
whereas a suitably engaged seat belt for thinner persons sits lower below the belly
creating more resistance on impact. With this knowledge, researchers are trying to
develop a new seat belt that factors in the weight of the occupants for the provision
of timing and force level when a seat belt is engaged on impact. The research is
also considering the application of inflatable seat belts where the belt inflation bag
quickly expands across the body to disperse the crash forces and reduce the impact.
The design ideas are all good examples of where manufacturers, designers, and com-
panies should be considering the anthromechanical concerns as they relate to the
overweight/­obese in the workplace.
Reshaping Lifestyle Changes 85

Performance Management
Another method that could be considered is using the best practice guide for man-
aging performance (­Fair Work Ombudsman, 2021). I have utilised this in the early
stages of identifying and managing overweight workers who cannot fulfil their role
or fail to comply with workplace policies and procedures. The best practice guide
allows the employer and employee to develop a framework for goal setting. It also
comprises an opportunity for constructive feedback and sets a benchmark for regular
­follow-ups about performance. I have utilised the performance system outline below
to manage the issue of obese and overweight employees. Specific elements include
the following:

• Expectations. Outline specific expectations during the employee onboard-

ing and company induction with references to healthy weight range for
employees for the safe use of plant and equipment. Expectations must also
be clearly articulated in the Health Management Plan, with specific goals to
be met, and acknowledged and understood by the employee.
• Template Agreements. This refers to the creation of the Health Management
Plan as described above.
• Discussions/­Feedback. This includes meetings with the employee to review
their progress and any future needs or determinations.
• Reward. This is about recognising and rewarding the employee for achiev-
ing goals in terms of weight loss or when he/­she has reached the final goal
and is no longer on the Health Management Plan.
• Review. This includes conducting performance reviews over the course of
the Health Management Plan and when the employee has not achieved their
goal by the agreed deadline. In the latter case, action commences to manage
the worker either through an appointment to another role (­if appropriate and
possible), or initiating the dismissal process.

Legal Position
The final element in the management of overweight workers is activated when all
other forms of management and initiatives have derailed, all avenues have been
exhausted, and the worker has not lost the required weight. It is at this time that
the company needs to determine its legal position from the employee perspective
that the worker can no longer (­safely) do the job they were employed to do. Also,
the company might now be keeping a worker in a role they were not employed for
in the first place. If the worker cannot be r­e-deployed to another role and he/­she
has become a liability, the employer may then commence the process of terminat-
ing their employment through the relevant employment legislation and/­or Enterprise
Bargaining Agreement or similar.
In addition to the preceding management elements that must have been effectively
adopted (­e.g. work system design, Health Management Plan, performance manage-
ment, and other health initiatives), a direction that a company can take and has been
relied upon in matters I have had to manage is utilising legal precedent (­a.k.a. case
law) or other industry standard practice to justify and validate the company’s position.
86 Ergonomic Insights

Importantly, in the early stages of the worker’s weight management, the employer
should have reviewed their legal position with reference to relevant legislation. When
reviewing an overweight worker and their exposure to risks in the workplace, the
company may have legal exposure related to its health and safety obligations even
whilst implementing the rest of the initiatives I described earlier.
For instance, Section 19 of the Work Health and Safety Act 2011 in Queensland,
Australia, mentions the employer’s Primary duty of care, whereby the employer
needs to ensure, so far as is reasonably practicable, the health and safety of workers
engaged, or caused to be engaged by the employer. If prepared to allow workers to be
seated on plant or equipment that does not meet the weight rating for the operator’s
weight, then the company has not fulfilled its legal obligations.
Similarly, though, workers may have also breached their own obligations. Section
18 (­Work Health and Safety Act 2011 (­Qld)) relates to the Duties of workers whereby
the worker must take reasonable care for his/­her own health and safety. When the
worker’s weight exceeds the safe working limits of a seat on plant and equipment,
he/­she has failed to ensure his/­her own health and safety subject to the worker being
aware of the respective limitations. These legal elements are crucial in the recruiting
and onboarding stages. If the worker enters the company and the employer has not
done its homework or exercised due diligence to check the weight limits of plant and
equipment and/­or advised the workforce about these, it will be much more difficult
to terminate an employee’s employment.
When it comes to citing industry standards on managing overweight/­obese work-
ers, the first notable example in Australia which sets a ­quasi-minimum standard for
other employers was the case of Metro Tasmania bus drivers in Tasmania (­ABC
News, 2012). In this case, bus drivers who weighed more than 130 kg were taken off
the job and put on lighter duties by the employer. The drivers were given six months
to lose weight, and they were also offered free medical consultation and gym access
to assist them with their weight loss. The company acted according to its policy. The
company had concerns for the employees’ health and safety in case the bus bottomed
out and the seat could break, thus causing an injury to the worker possibly attributed
to the mismatch between personal weight and maximum allowed weight of the bus
seat.
Whenever I must deal with overweight workers regarding exceedance of maxi-
mum safety capacities, I often print and hand out the article cited above. I also use
the ­six-month time frame adopted by Metro Tasmania as the same benchmark for the
employees of the company I work with to meet the required weight range. In terms
of the desired weight to achieve, the weight the employee and management normally
agree upon in consultation with the medical doctor is a few kilograms below the
maximum safety rating; this affords the worker some wriggle room. Similarly, after
the weight range is achieved, the worker and management commit to f­ ollow-up ses-
sions of about 15 minutes twice a month for three months. These sessions are to
verify that the worker maintains a safe working weight and any potential hurdles
going forwards that we can support and/­or for which we can prepare.
A similar case regarded overweight miners at specific Bowen Basin mines in
Queensland in 2012, who were stood down from work until their weight was under
120 kg before being allowed to return to work (­Courier Mail, 2012). The Department
Reshaping Lifestyle Changes 87

of Employment and Economic Development, which was the mining regulator at the
time, was consulted by the newspaper. The department stated that whilst there was
no mining safety legislation that could ‘­impose minimum or maximum weights for
persons working in the mining industry’, the Queensland legislation does require all
mines to ensure they have safe operations and manage risk for their workers. This
included fitness to work within the requirements of the safety and health manage-
ment system. The department’s position aligned with the employer’s primary duty of
care mentioned above.
The final element that an employer can rely upon in managing an overweight
worker is legal precedence in the form of case law as this sets the minimum legal
standard for similar cases. A prominent case is that of Ranui Parahi v Parmalat
Australia Ltd (­2015) FWC 7191. In this case, the worker was a cool room operator
with a requirement to operate a forklift truck as part of his role. The forklift had a
seat rating of 175 kg, and the worker weighed 165 kg at the time. In June 2014, the
worker was stood down from work until he was able to manage his medical issues (­i.e.
sleep apnoea which posed a risk to the operation of machinery) and resume duties.
The worker had been assessed by a specialist occupational physician who deemed
him unfit for work and recommended standing the worker down. Subsequently, the
worker was placed onto a treatment plan, which included weight loss (­Lehrer, 2016).
However, when the worker was reassessed in February 2015, his weight had
increased to 175 kg. The independent physician determined the worker could no lon-
ger undertake manual handling tasks or use machinery such as operating a forklift.
The worker was subsequently dismissed because his weight rendered him unable
to safely perform the requirements of his role. The worker filed an unfair dismissal
claim with the Fair Work Commission, and the proceedings determined that the
employer had valid reasoning in terminating the employment as the worker was inca-
pable of safely carrying out the inherent requirements of his role (­Lehrer, 2016).
I believe the few examples above outline adequately an employer’s position
whether it is about placing someone onto a Health Management Plan such as in
the Metro Tasmania case, standing down someone from work until they reach a set
weight range as per the Courier Mail article in the mining sector, or justifying why
a worker is dismissed because they can no longer complete their role due to weight
gain as per Ranui Parahi v Parmalat Australia Ltd (­2015) FWC 7191.

CONCLUSION
The topic of weight management in the workplace can be prickly in nature and is
a complex subject with challenges for everyone involved, including the impacted
employees, management, and other key stakeholders. When contemplating solu-
tions for addressing weight management in the workplace, it is imperative that the
employer considers the work system with the highest priority. This can refer to the
design of systems and processes, anthromechanics in equipment design, recruit-
ment and onboarding, and other workplace initiatives, as opposed to focusing on the
employee from the outset.
From a pragmatic perspective, the ideal situation of adapting continually the sys-
tems to each worker may not be feasible. Employees come in all shapes and sizes.
88 Ergonomic Insights

Therefore, whilst consideration needs to be given to the maximum possible inclusive

design of the workplace and organisational systems, this might not be always practi-
cable. Also, as I explained in the ‘­failed’ case in the beginning of my chapter, rushing
to change without a holistic assessment can generate more problems. This, engaging
professionals with adequate and proven skills and experience, like certified ergono-
mists, should be one of the options to consider.
Notably, employers are the ones who first carry the responsibility for deciding
and acting proactively. They must understand the design parameters of job require-
ments, including specifications and limitations of safe equipment use. Such an analy-
sis, which can be performed and supported by ergonomists and other specialists, is
important to support the adaptation of the organisation to restrictions and constraints
outside its control (­e.g. given equipment designs) whilst, in parallel, continually
searching for more ­design-inclusive alternatives. The goal must be to support and
influence employees, not to control them.
Furthermore, besides technical parameters, the integration of health and
­well-being measures can promote worker health by using the workplace as an envi-
ronment which enables better health choices and habits of which workers might not
be aware. However, whilst initiatives like the above must be subject to regular con-
sultations, reviews, and updates, we cannot exclude cases where they do not deliver
for everyone.

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 8 Indian Farm Tractor
Seat Design Assessment
for Driver’s Comfort
Bharati Jajoo
Body Dynamics

While driving, you check the r­ear-view mirror often and view the scene that you
passed. You have already passed it, yet you keep looking, checking to gauge traffic
and speeds of other road users, checking if any safety hazards are still there and so
on; although you are in the front, you still look back. Checking the ­rear-view mirror
while driving is such an important habit to master.
The opportunity to share insights for a ­practice-focused book felt like a similar
exercise: to review and appreciate learnings. What experience teaches you is to do
more of the same or not do it at all. God’s greatest gift to mankind is the ability to
learn, improvise, and do things in a certain way. While thinking about writing this
chapter, I pondered my learnings and insights from ergonomic design. One of the
assignments that stood out in my memory, even after a decade, was the opportunity
to work on the reduction of low back pain for tractor drivers.
Agriculture is the primary source of livelihood for about 58% of India’s popula-
tion, and so the role of modern tractors has become increasingly significant. Tractors
have improved the capabilities of farm work and production fivefold. Tractor produc-
ers recorded their highest ever sales in ­2017–2018. Selling over seven lakh units, a
number expressively higher than the 5.9 mark in 2­ 016–2017, the 22% increase in
tractor sales indicates that farmers are opening to the idea of investing in multipur-
pose tractors, with their penetration improved from 1­ -­per-150 hectares to ­1-­per-30
hectares.1
A leading farm tractor manufacturer contacted me with a request to help them
make the driver seat more comfortable for the operators of farm tractors. At the out-
set, it sounded very interesting. My instant joy of being able to work on tractor seat
design was beyond boundaries. My father was an orange orchid farmer/­grower, and
my grandfather was known for the advanced agricultural practices of his times in our
area. I grew up partially in an Indian village. As a child, I had many rides in a tractor
that were considered a big advancement from the bullock cart.
At that time in India, transport in villages had fewer choices. Tractors were used
from agricultural tasks to ferrying people to their field jobs, and from wedding

1 https:// ­k mwagri.wordpress.com/­2 018/­0 9/­19/­­i mportance-­of-­u sing-­t ractors-­i n-­modern-­agriculture-­

kmw-agri/

DOI: 10.1201/9781003349976-8 91
92 Ergonomic Insights

processions to carrying patients to the hospital in an emergency. I saw the utility and
importance of these vehicles from many angles. Therefore, this opportunity to work
on the improvement of the farm tractor seat design was exciting. Being a farmer’s
daughter, I could contribute my part with the right product design from a human fac-
tors and ergonomics (­HFE) perspective. With the right HFE design, I could help to
alleviate the most common and, at times, debilitating back injuries of farm tractor
drivers.
I believe that the right system and work design leads to prevention, efficiency,
and ease of operations for the users. Notably, musculoskeletal injuries happening at
the field level during agricultural activities are often not recorded, meaning little to
no data are collected. It is an unorganised sector in India and lacks regulations for
employee health, safety, etc., although such protective provisions may be a norm in
many western countries.
Traditionally, Indian tractors are driven by hired drivers rather than owners.
However, a market survey conducted by the client revealed that customers were seek-
ing increased comfort coupled with better product performance. The market research
also pointed to customer feedback indicating complaints of low back pain. Although
no precise statistical data on low back pain were available, the feedback was com-
pelling enough to encourage the client to build a new prototype and, amongst other
objectives, address the low back discomfort issues related to tractor seat design.
Admittedly, I felt nervous when I was assigned this project as I did not have expe-
rience in the ergonomic design for tractor drivers. I was unsure of how I would go
about it. Nevertheless, with enthusiasm and a solid understanding of the basics of
ergonomics from more than 15 years of experience, I embarked on this exploratory
journey. During our initial communication, it sounded difficult to lay down the scope
and expectations of the team in charge without sighting the product. It was about a
prototype and did not exist yet! Hence, the request to assess the currently available
product proved helpful.
One thing I wished at that time was to have a mentor or any senior to guide me on
unusual topics or projects. They do say that you are alone at the top, and that is the
feeling I had while we were in the process of defining the scope and deciding mile-
stones. Consequently, my first visit to the client’s head office to review tractors and
hold discussions was a mixed bag of experiences. On the one hand, I felt excitement
for doing something new to me, and, on the other hand, I was unsure of not know-
ing how I would go about it in terms of defining the scope, precise data collection
methods, risk identification, etc. I was thankful that I had previously read about trac-
tors and their basic mechanics. This meant that I could engage in somewhat relevant
discussions and understand more about the mechanical engineering aspects of the
product. However, during this first visit, I realised I was unaware of the various trac-
tor controls and terminologies used. Everything was new, and the product function-
ing was so different from my previous design experiences in designing for low back
support, chair seat design, etc.
Luckily, an engineering team member that gave me the information was enthusi-
astic about providing the details about the mechanics, the engine horsepower, how
the engine worked, and what mechanical engineering improvements were in the
planning process. “­Madam”, he said, “­all you need to do is give us a good seat design
Indian Farm Tractor Seat Design Assessment 93

and our prototype will be ready in a few days!” In this visit, I was trying to gather and
filter information relevant to ergonomic risk factors identification. However, although
I had been given an overload of information, there was nothing relevant that would
help me for the goal of this first interaction with the client. I was looking for the ergo-
nomic risk factors, but the engineering team obviously did not think about human
factors. They were more focused on the technical specifications and product per-
formance rather than how the user interacts with the product and how this affected
health, safety, etc. This probably leads to their simplistic view of just getting the right
seat design from a technical perspective.
When I performed a preliminary observation, I realised that my data intake form
lacked many aspects of the assessment required. To my surprise, I was not allowed
to take pictures on this visit due to commercial confidentiality reasons. Thus, I was
dependent on sketchy drawings and line diagrams to draw up my initial format.
During an ergonomic risk factors assessment, observing h­ uman–machine interac-
tions is essential to understand and evaluate how tractor drivers operate all required
controls without compromising safety and what could pose risks of developing mus-
culoskeletal disorders.
I wish to note that when it comes to product evaluations, I am more of an intuitive
user. I prefer to first try to use the product and understand its limitations and capabili-
ties. However, on this occasion, I did not know how to drive a tractor, operate various
controls, and use the added features required for farming. Nevertheless, just getting
in and out of the tractor as well as sitting in a stationary tractor made me realise that
there was more than just a driver’s seat design to make this driver’s seat comfortable
without increasing low back pain discomfort. The most apparent factors I felt right
away were ingress and egress on a high step and the awkwardness of reaching to the
driver seat and important peripheral driver controls.
Before my visit ended, I had to prepare a preliminary presentation to the team
about my risk assessment, its findings, and a recommended plan. I had to do all this
before catching my return flight in two hours. As the scope was assumed to be only
related to the driver seat, the team was expecting me to give a complete report on it. I
was fortunate to demonstrate my findings while standing in front of the product, and
I could give the team a visual demonstration to aid their understanding.
They seemed pleased with the demonstration with their heads nodding in agree-
ment or understanding my explanations, but I was unsure if the client would move
forward with the development of the new prototype based on the findings of an exist-
ing model. After all, I was talking about a long list of factors such as ingress/­egress,
control panel, design, visibility, etc., and not just seat design as anticipated by the
engineering team. The client thought that all that might be needed would be a simple
change of the driver’s seat by giving it a certain shape or change of foam/­cover, or
similar. Thus, perceived problems and solutions by the team differed from my find-
ings of various ergonomic risk factors that could influence driver’s comfort. Simply
put, my findings extended beyond the need for the redesign of the driver’s seat.
I was left with the impression that a simplistic r­ e-design of the seat was the solu-
tion expected by the team, and an exhaustive list of ergonomic factors that required
broader consideration for ­re-design may not have been of interest to them. After I
concluded my visit, I did not hear from the client for weeks, so I assumed that things
94 Ergonomic Insights

would not progress. To my surprise, though, I got a call stating that we could go about
the next steps in a phased manner. Later, I was informed that during their internal
discussions while contemplating this project, they decided to hire an internal indus-
trial product designer, rather than rely only on the engineering team.
Hence, in addition to the engineering team and me, the team included industrial
product design specialists. However, we all were novices in designing a similar prod-
uct prototype. There were no clear specifications or w­ ell-defined processes disclosed
by the client or known to us. Therefore, it was a discovery journey for the team.
Looking back at this initial project stage, having had some experience in similar
product design would have helped to map the steps and milestones. I believe that we
would have had a similar outcome in terms of the resulting product, simply because
we followed a ­human-centred approach to the design, but we may have arrived at our
endpoint faster and more efficiently.
Our first small win was the formulation of our problem statement:

• Users/­drivers complained of the tractor seat being uncomfortable, causing

low back pain.
• Need to improve the seat design of a new tractor prototype that was being
considered as an upgrade for the new model.

The client’s objective was to provide seat comfort for the tractor driver. How to go
about it was the essential question for the product team. The client still believed
that changing seats through minor modifications would improve comfort adequately.
After our preliminary discussion, our primary goal was to assess the ergonomic risks
from the perspective of the seat design as well as various peripheral driving controls
and tasks (­e.g. operating the clutch, breaks, accelerator, and steering wheels; and
ingress and egress [entry and exit]). This would lead to a more complete assessment
and minimise the risk of low back pain for drivers.
The challenge was that during my literature search on how to evaluate tractor
seats and other peripherals, I could not find any standard formats or standardised
tests that would suit our problem statement and design goals. Hence, I prepared and
improvised on the required aspects and features necessary for the assessment and
created my own ergonomic data collection format. The ergonomic analysis form was
developed based on seat evaluation by the drivers, anthropometric measurements of
seats, measurement of the location of various controls, and any obvious safety risk
for the drivers. This format assisted me in the risk identification and communication
with the team, ultimately aiding the ­decision-making.
This project made me realise that if standardised HFE tools do not exist or are
not known, foundational design processes can be undertaken. For us, this meant that
we reviewed our goals and objectives, and developed our own data collection instru-
ments, while adhering to the tenets of h­ uman-centred design, such as involving sub-
ject matter experts and analysing human tasks. My simple but critical principle in the
ergonomic assessment for product prototype and design is to incorporate everything
that matters from the driver’s perspective. A clinical occupational therapist needs to
adapt when standard tools and formats do not match the purpose or objective of the
evaluation. Standard tools at times do not help in a comprehensive view of ergonomic
Indian Farm Tractor Seat Design Assessment 95

risk factors present or to fully manage the process of their prioritisation, directing
resources, etc.
An inclusive data collection instrument that does not ignore any important system
parameters is one of the most important aspects of ergonomic processes, as this is a
starting point, the first step to make impactful changes. The ergonomic design pro-
cess can be nuanced because of the context of equipment use and human tasks, so
the design process must be agile, adaptable, and iterative (­back and forth as learnings
may happen). I feel that accepting the challenge with many unknowns and figuring it
out while keeping in mind scientific principles/­methods of human factors/­ergonomics
has worked well for me with one rule to follow: be very thorough in your evaluation.
Armed with my assessment, I helped the team understand my point of view on
ergonomic factors, won their confidence, and eased my doubts of how to go about
it. In the first step of the ergonomic assessment, the method used was an observa-
tional method coupled with job task analysis and anthropometric measurements. My
assessment findings explained to the team were mostly in relation to tractor drivers’
exposure to ergonomic risk factors leading to awkward posture, excessive pressure/­
effort, and contact stress. My initial observation list included aspects such as a high
step and awkward reach to pull oneself enough to reach the driver seat; obstacles
in the way to reach the driver seat; hard backrest with slippery seat cover; and high
effort to push/­pull the seat adjustment lever below the seat. The findings regarded the
design and use of almost all system elements (­e.g. steering wheel, hand accelerator,
clutch, brake and accelerator pedals, gear and range shifter levers, parking brake, and
control panel switches).
The referred objective of the ergonomic assessment was to come up with the right
seat design for the tractor driver’s comfort. However, that became a secondary objec-
tive for me. When we discussed the above, the next steps seemed a bit overwhelming.
Where to start making these changes on the prototype considering the budget, staff-
ing and time limitations? Thus, I first had to convince the team to prioritise safety
concerns of ingress/­egress of the tractor, climbing over the uneven floor of the tractor,
and lifting legs to clear the floor when getting to the seat.
I was sceptical about the team’s reactions to changing the course of action needed
to make the product safer and comfortable. To my delight, the team was convinced
and suggested looking at product design improvements in two phases. For the first
phase, we decided to work on drivers’ safety to ensure that they could get in and out
of the tractor without hurdles and potential risks of trips, falls, and awkward pos-
tures leading to musculoskeletal disorders. Second, we contemplated seat design and
drivers’ interactions with the peripheral controls, which would be important for the
comfort of the driver.
While everything seemed important, we had to pick the first line of defined and
measurable changes that could be incorporated in the initial prototype of the design.
My first presentation successfully demonstrated the safety risk of getting into the
driver’s seat which was related to high, uneven steps, ­poor-quality foot holdings, and
gear lever on the floor obstructing driver’s access to seat as well as sitting position,
making driver’s hip to remain in wide abduction while driving. These helped the
product and engineering teams to understand the need to come up with engineering
controls.
96 Ergonomic Insights

In the old model, the entry to the tractor was open using a high step, and there
was no designated handrail to hold. Instead, the steering wheel and the side fenders
of large wheels were used by operators to pull themselves into the tractor. Simply
put, getting in and out of the tractor was no less effortful than climbing a big hur-
dle. Traditional farm tractors do not have doors! Hence, in this first phase of the
new product design, we established and implemented some concrete physical safety
parameters such as steps at the right height and with ­non-skid covering, adding hand-
rails and relocating the floor gear lever. The engineering team’s objective to engage
with ergonomics prior to designing new prototypes gave them the most important
aspect of a product: user safety first.
Based on the ergonomics standpoint, the engineering team created two steps with
improvements in height from the ground, along with improved length and width
required for full foot placement. A narrow high step extending outwardly out of the
external profile of the tractor in the existing product was replaced with two steps.
­Table 8.1 presents some measurements on which the new prototype was based. The
testing of these features by the team members suggested that the new design felt
comfortable and secure. It would reduce the risk of trips, falls, and musculoskeletal
disorders when adopting unnecessary awkward postures to get in and out of the trac-
tor. Moreover, the fact that the length of the step was not extending out of the outer
profile of the tractor reduced safety risks to pedestrians and other vehicles or when
parking or driving on narrow and often barely motorable streets in villages.
Moreover, the flooring of the tractor was made of weatherproof black plastic
material with a grooved texture. This seemed like an afterthought to protect the
floor from all weather conditions because the floor was uneven. It seems like an
­ad-hoc addition to cover the floor. This uneven floor was a trip hazard. Most often,
Indian truck drivers use ­open-toed footwear, which may get caught on the flooring.
Given this input, the engineering team designed the floor space clear of obstructions,
­well-levelled, and weatherproof (­i.e. India has tropical weather, and the tractors are

­TABLE 8.1
Example of Design Changes of the Tractor Entry
Measurements
Previous New Product
Variable/­Factor Model(­mm) Prototype (­mm) Comments
The first step from the 520 501 Less strain on the leg
ground
Distance between steps 135 230 Improved stance
Inside width of steps 150 280 More surface area and stability
for foot placement
Max. length of first step 253 290 More surface area and stability
for foot placement
Length of step that is 152 None Reduced safety hazard
extended outside
Indian Farm Tractor Seat Design Assessment 97

heavily used in the rainy season when farming activities are at their peak). Also, in
the new prototype, a grab bar of 100 mm length with a 10 mm addition of textured
grip was installed. This would help to securely place hands and enter and exit out of
the doorway to get to and out of the driver’s seat without relying on wheel fenders
and the helm.
Often, establishing priorities or changing the course of a product design prototype
is a delicate matter because new designs constrain time and budget, and there can
be limitations on skilled manpower resource allocation. However, despite being a
novice product design team, we managed to assess the risks, set objectives, develop,
and test prototypes. Witnessing the success of our first phase of the new product
prototype was gratifying. This has now set us on our next phase of product develop-
ment, and we were excited to further discover, ­problem-solve, test, and get approvals
to progress further.
Regarding our next phase, the seat design, I had earlier realised that comfort was
not just related to shape, size, contours, or quality of foam. It was much more than
that. Through my experience and background in job activity and task analyses, I
understood that the place you sit/­stand on is as important as what one is doing while
sitting. That ­human–machine interaction is part of “­the essence of ergonomics”. Even
if the driver sits on the b­ est-designed tractor seat, she/­he will need to operate vari-
ous peripheral controls and apply forces required to adjust seat levers and reach the
hand accelerator, seat pedal, brake pedal, accelerator pedal, gear shifter lever, oper-
ate various types of switches, and adjust mirrors to ensure visibility.
Indeed, the specific seating characteristics (­e.g. length and height adjustment,
shape of backrest and seat, or quality of foam covering) still mattered for the driver’s
comfort due to the required forces to operate some controls while sitting. The loca-
tion of the gear control lever in the middle of the legroom affected the normal sitting
position of the driver. The driver had to sit with wide open legs almost towards the
end range of hip abduction. Hence, to make the driver seat comfortable, we needed to
address most of these issues. I faced challenges in articulating what would be needed
and explaining an exhaustive list of features required for comfortable sitting while
operating the tractor and performing various farming operations.
Nonetheless, following the initial success of demonstrating the required product
design and having a successful working prototype, the team was open to receiving
and understanding the requirements. We started with a focus on the first level of
driver seat improvements. By using a “­look, feel, and fit” approach, we consulted
with the anthropometric data we had collected and made improvements related to
seat height, seat pan depth, backrest design, and armrest height. Apart from the static
components of the seat, we also worked on dynamics controls for seat adjustments,
spring tension, and the length of levers, as well as the addition of a driver seat safety
belt that was missing in the existing tractor model.
The team was pleased with the improved features but understood that this was not
sufficient for the established goal. The goal was to achieve adjustable seat features
for a better sitting experience while operating various controls. Additionally, the next
step was to work on minimising awkward reaches and difficult grips of peripheral
controls. For example, the gear lever with top knob moulded to keep grip in the wrist
neutral position was moved to the right side of the driver seat for ease of operation
98 Ergonomic Insights

(­i.e. instead of the current location being in the middle of the driver’s legroom area).
This minimised awkward postures with excessive reach and forward bend as per
the operations in the previous model. Next, we would discuss as a team and agree
upon the set of changes to be added for the next prototype assessment. It took several
months to get the display unit, clutch, accelerator, brake pedal, hand control, steering
wheel, position control, etc., ready for review by the entire team. The new, improved
version of the prototype was developed, tested, and retested against the established
ergonomic design objectives.
Despite all the doubts when I started on this project, the engagement with a nov-
ice team and the journey of working through various milestones led us to generate
a prototype that resulted in a new prototype of a tractor. In my role as an ergonomic
expert, I learned that looking at all details of a product and appreciating the mul-
tiple facets of interaction between humans, equipment, and tasks involved leads to a
thorough and inclusive evaluation. This, in turn, offers a complete understanding of
ergonomic risk factors and supports the process towards the generation of solutions,
which, when accepted by the team and stakeholders, lead to successful outcomes.
Armed with the success of this prototype and the launch of the new model in
the market, the team aspired to continue with more improvements in new products
launched for different categories of farm activities. There was a market demand
for better, improved models to support the economically changing conditions that
included improved purchasing power of Indian farm owners. Thus, the company
leaders wanted to move forward with the next improved and ­state-­of-­the-art tractor.
This would have a proper enclosed driver cabin, be more comfortable with climate
control options and highly adjustable seat options for maximising comfort. They
wanted a tractor that would contribute to the least possible fatigue. Following this
vision for a more advanced tractor model, we had multiple meetings.
I tried to help the team understand ergonomics in greater depth, especially for
features such as designing closed driver cabins with climate control options. Also, to
improve the next tractor model, we needed consumer feedback to sense whether the
competitive Indian farmer would be receptive to a more advanced model. This would
require extensive research and considerable effort. Once those prerequisites were
understood by the team, they realised that to implement their vision of ­state-­of-­the-art
tractor, greater effort was required along with bigger investments, advanced skillsets,
and increased staffing.
Admittedly, the next product was a more complex problem to solve. Also, the
company realised that i­ n-house ergonomic experts would be required to build a new
prototype. Although I did not get to work on the next model, still there was a big
win. The company started considering ergonomics as an inextricable part of product
design! That was a huge success as it would lead to a better quality of future products
and benefits for the end customers, the Indian tractor drivers. As a farmer’s daughter
whose revenues depended on farming and the effective use of tractors, having the
opportunity to help drivers through ergonomic tractor design will forever remain
a great experience for me. Moreover, becoming part of a team with multiple disci-
plines pushed me to improve my knowledge in other areas and work with everyone
to realise the new product design.
Indian Farm Tractor Seat Design Assessment 99

When looking back, I believe that I should have first worked on developing a
complete vision of the design and the steps/­phases involved. I think that this would
have made it easier for the team because they initially thought that it would be only
a ­one-step assessment to generate redesign recommendations. However, ergonomic
design is always challenging. Whatever design you are working on, the context of the
equipment, the users, and their tasks and needs must be considered using scientific
methods.
Moreover, developing measurable and concrete milestones broken down in sev-
eral phases of product development would be improvements that I want to implement
in future projects. Also, I would like to know beforehand the roles and responsibili-
ties of all stakeholders involved in the design process. Quite often, there were new
members and new roles added which made it difficult at times and impeded the speed
of the process because, each time, we had to review the project and help the new
members understand the design process and objectives.
Successful outcomes can be achieved, and harmonising team efforts is “­doable”
when we connect the dots of our diverse experiences, and we remain open to learning
from our past work projects.
 9 ­ ff-­The-Road Tyre
O
Management
The Good, the Bad,
and the Ugly
Paulo Gomes
Segurança Diferente

CONTENTS
Let’s Empower the ­End-Users to Finish the Design............................................... 103
Changing a Standard Requires More Than Good Will........................................... 105
In Hindsight............................................................................................................ 108
References............................................................................................................... 108

If you had to think about a ­high-risk activity in mining, what would come to your
mind? Mining blast? Perhaps operators of those large trucks? Think again. According
to Rasche (­2019, 6:15), ­off-­the-road (­OTR) tyre fitting is so risky that people working
with tyres, tyre fitters, “[…] are between 10 and 12 times more likely to be fatally
injured than a mine workshop maintainer fitter”. Amongst mining maintainers, tyre
fitters are often seen as low maintenance workers within a workshop hierarchy. The
tyre bay, where tyre maintenance occurs, is often an improvised work area normally
located in the corner of a workshop.
If someone wants to become a tyre fitter in Australia, they will be required to
complete a formal training called AURKTJ011 Remove, Inspect and Fit Earthmoving
and Off-The-Road Tyres.1 In theory, this training should provide the trainee with
sufficient information so that they can identify and manage all critical risks related
to removing, inspecting, and fitting earthmoving and OTR tyres. However, to my
knowledge and experience, the training is mostly conducted in class, supported by
slides, and with little opportunity to practice. When some practice happens, it is
typically with s­ mall-scale models of a wheel and tyre to match the environment of a
training workshop. These limitations could be attributed to a large number of types
of OTR wheels and sizes available, making it extremely difficult for registered train-
ing organisations to exactly represent the work conditions that tyre fitters will face
on a mining site.

1 https://­training.gov.au/­Training/­Details/­AURKTJ011

DOI: 10.1201/9781003349976-9 101

102 Ergonomic Insights

Assembling a wheel and fitting a tyre are complex tasks. Several original equip-
ment manufacturers (­OEMs) and different designs of OTR wheels are in use in the
mining industry. Some large sites operate with almost all types of OTR wheels,
including ­single-, ­two-, and m
­ ultiple-piece wheels. ­Large-haul trucks, those massive
vehicles that normally carry a great volume of ore from the mining pit to the dump-
ing area are usually fitted with OTR wheels composed of multiple pieces, and they
are fitted with the largest tyres in the world. These tyres operate under such extreme
internal pressure that they are described as ‘­moving bombs’. Something can easily go
wrong so that the violent pressure release can transform any part, including a small
piece of rubber, into a projectile. Surviving an accident with those tyres is nearly
impossible (­Taylor, 2010).
Over the years, research investigating ­haul-truck improvements has been focussed
mainly on the performance of the engine and carrier capacity of the truck. Different
OEMs have developed their own OTR wheels, which contain several components
that seem to be similar, but because of slightly different angles, cannot be mixed If
components from different OEMs are mistakenly put together, or assembled in the
wrong order, a catastrophic disassembly of the wheel assembly can happen. More
specifically, the lock rim, rim base, and bead seat band are the three main compo-
nents of a wheel that have killed people when assembled wrongly. Despite several
fatal accidents involving mismatching wheel components, the design of OTR wheels
has seldom changed for almost half a century. What is worse, the AURKTJ011 train-
ing does not mention anything about these parts or the risks if they are assembled
wrongly (­Rasche, 2019, 20:31).
There are a high number of possible combinations when assembling a wheel, com-
pounded by time pressures which can contribute to hazardous working conditions.
Having a truck stopped for heavy maintenance is one thing. The other is having an
unproductive truck because of a problem with the wheel or tyre. In addition, several
tyre changes are performed at night, in the dark, with poor visibility of the tyre and
parts. Components are also required to be properly cleaned to remove any signs of
rust, aggravated by the possibility of mixing components from different OEMs. This
is a receipt for a disaster.
In recent years, significant improvements have been noticed in Queensland (­QLD)
and Western Australia with the release and enforcement of tyre management stan-
dards and guidelines by their respective Mine Departments. Nonetheless, critical
hazards to the activity such as thousands of possible assembling combinations given
the number of components of a wheel, the lack of standardised wheel design, and
poor identification of the parts are well documented and known. There is an imprac-
ticable expectation that each tyre fitter will manage these risks on the job (­Hassall &
Boyle, 2016). In addition, the lack of conveying critical information in some training
programmes and the working conditions of a tyre fitter remains unaddressed.
Against this background, I share two cases that convene my experience when
I worked for a large Australian OTR tyre management company overseeing their
operations across QLD, New South Wales, and New Zealand. Given my background
in working as a safety specialist in mining sites around the world for several years,
when I joined the company I thought that I knew enough about mining and tyre
management. However, as the stories will tell, I could not be more wrong. Not long
Off-The-Road Tyre Management 103

after starting the new job, I realised that the situation was more complicated than
anticipated.
The first case is about success, creativity and appreciative inquiry (­Whitney et al.,
2010). One of the first things I proposed when I started the new job was the introduc-
tion of a new way of collecting safety information from the tyre fitters. Rather than
hazard reports or behavioural observations I proposed to talk directly to the fitters.
Further to collecting information about what can go wrong, I decided to open the
space for people to share insights to improve the safety and productivity of their work
(­Provan et al., 2020). Therefore, in the following section, I describe how the work of
the tyre fitter improved with the ideation, design, creation and implementation of a
new tyre fitting tool.
However, life is not only made of good stories. Experiences that do not go as
expected can also teach us a lot, or even more, as some say. In the second case, I am
presenting the dark side of technical standardisation. The Regulator, other stakehold-
ers, and I tried to push for a change to the Australian Standard 4457 on OTR Wheels
and Tyres (­Standards Australia, 2007). Little did I know about the politics involved
in amending standards. The mining industry is powerful and can lobby against safety
initiatives whenever the changes to regulations or standards increase the costs or
impose additional hurdles to their businesses. At the end of this story, I reflect on the
lessons learned on the ‘­battlefield’.

LET’S EMPOWER THE ­END-USERS TO FINISH THE DESIGN

This first case relates to when I decided to change the culture of my organisa-
tion around 2015. Back then, the focus was almost entirely on managing numbers
imposed by clients, mainly large mining operators, who were interested in measur-
ing the number of hazard reports against actions completed. However, ‘­the number
of hazard reports done tells us nothing about their quality’ (­Smith, 2018). There was
no space for consultation or contextualisation because they believed that workers
only needed to follow their procedures to be safe. That was not surprising as several
mining managers believe that most accidents happen because workers either did not
follow a procedure or there was no procedure to follow (­Laurence, 2005).
Incredulous with the context, I decided to introduce the appreciative inquiry
approach to engage the workforce to identify successes and strengths that, in
turn, would move the organisation to our desired future. The term ‘­appreciative
inquiry’ was first coined by David Cooperrider in 19802 and aimed to serve as a
­problem-solving tool based on the positive aspects of the organisation rather than the
negatives. Four steps drive the appreciative inquiry method, commonly referred to as
4Ds (­Cooperrider et al., 2008):

• Discovery, where the best of previous and current experiences is discussed

with participants, exploring what motivated the inquiry.
• Dream, when participants are asked to imagine their group, department or
organisation at its best.

2 https://­www.davidcooperrider.com/­­ai-process/
104 Ergonomic Insights

• Design, where participants are invited to describe what the organisation

should be with provocative propositions.
• Destiny, the final step, aims to evaluate the proposed ideas and implement
them.

Applied to safety, appreciative inquiry is conducted as a focus group, in the work-

place, with different frontline workers from a particular operation participating in
the session. They are invited to discuss the process, procedures, tasks, activities, and
work conditions in general (­Discovery). Normally, the initial part of the session leads
to the acknowledgment of risks, actual practices and challenges in the ways of work-
ing. Next, they are asked what the ideal work and its setting would look like (­Dream).
Then, they are invited to share ideas of new ways to do their work (­Design). Using
the information shared, the safety specialist and the engineering department can
translate the needs, dreams, and proposals into practical solutions to be implemented
in operations (­Destiny).
In one of the appreciative inquiry sessions I conducted, a Senior Tyre Fitter shared
that changing tyres on an EH5000 haul truck was riskier than most of the other haul
trucks. The Senior Tyre Fitter reflected on one day when a new EH5000 haul truck
was delivered to the mine site he was working. Five fitters from the truck OEM were
required to assemble the wheels containing a dozen large steel pieces called spac-
ers. The spacers must be positioned inside pockets around the wheel drive to secure
the wheelbase. Given the intricate aspects of fitting a dozen spacers, the OEM fitters
used a large and bulky tool suspended by a Franna crane. Two fitters supported the
tool above their heads while trying to align each spacer to fit into the pockets. This
activity continued for half a day. The Senior Tyre Fitter observed the task and listed
several things that could have gone wrong with the work observed, some of which
could lead to fatal injuries (­e.g. hands being caught between the tools and the wheel
and uncontrolled movement of the suspended load).
The Senior Tyre Fitter recounted that he spent days thinking about how this task
could be done differently, safer, and more efficiently. He then selected a couple of
steel tubes, adapted a crowbar and created a proof of concept of the ideal tool to help
with fitting the spacers. However, because he was not sure whether the tool would be
well received by his colleagues and supervisors, and because sharing new ideas in
the past was deemed risky and improvisations were reprimanded, he kept everything
to himself, under the workbench in the tyre pad.
Fortunately, during the appreciative inquiry session, the Senior Tyre Fitter revealed
the tool, explained the rationale, and provided detailed instructions on how to use it.
I was hooked. Still, on the spot, the session participants brainstormed the concept,
worked on a couple of technical drawings of the tool, and defined some requirements,
including that it had to be light, strong, with no sharp edges, and easy to manoeuvre.
I then promised to take the idea to the office and evaluate the feasibility of creating
a prototype of this tool.
The safety department did not have a budget to pay for the prototype. Moreover,
the safety manager would not approve it because one of the organisation’s most prof-
itable projects had just come to an end. I then decided to contact an engineering
company that manufactured a couple of work platforms for us. I asked if they could,
Off-The-Road Tyre Management 105

as a favour, use scrapped steel pieces to put together a rough prototype of the tool so
that it could be used on trial. The company agreed!
Once the rough prototype was ready, a first qualitative risk assessment was com-
pleted for the use of the tool, and we concluded that it did not introduce any side
risks. Then, the idea was presented to the organisation’s management team and
the client (­i.e. the mining operator) on site. The client was fascinated by the idea
and requested to observe the trial. Even with the rough prototype, the task did not
require a Franna crane, eliminating the most critical risk from the task. It could be
safely performed by one person (­i.e. not a team!) holding the tool below shoulder
height, and the task was completed in approximately three hours (­i.e. half of the
time!). The client was so impressed that they offered to pay as much as it would
cost to develop a proper tool. Three prototypes were developed and tested in a
period of six months until everybody involved in the project was happy with the
final design. The final tool is comprised of a set of three clamps made up of stain-
less steel, and it comes with a user manual. The tool was so relevant to the tyre
fitter work that it was shared with ten other mine sites owned by the organisation
in Australia and overseas.
This story teaches us that while safe work may be an objective, task redesign
usually leads to improved efficiencies. It shows that listening to the workers and the
frontline people should be one of the main goals of leaders who want to positively
impact the workplace. Our workers know the problems, and they could also have the
best ideas for the most suitable solutions. As important as it is to listen to and engage
with workers, changing the work conditions should also be our priority since we have
access to more resources than a shop floor worker. The solutions should be profound
and should start small, with a concept or prototype to be validated in the first place.
Then, a ­small-scale pilot validation should be conducted to evaluate the feasibil-
ity and any additional risk added by the solution. Once the prototype is validated
and new risks are revealed and properly controlled, the tool can be implemented
widely. However, it is important to keep in mind that the solutions are never perfect
and require continuous adjustments over time based on feedback from r­eal-world
implementation.
In 2017, this tool redesign project was submitted to the National Safety Awards
of Excellence in Australia and won an award in the category of Best Individual
Workplace Health and Safety Achievement (­Godwin, 2020).

CHANGING A STANDARD REQUIRES MORE THAN GOOD WILL

The fitter tool explored in the previous section, despite being incredibly effective,
still does not prevent the potential risk of mismatching components. Several OTR
­tyre-related fatal accident reports and most of the tyre fitters with whom I worked
agreed that trying to assemble a wheel with unidentified components or compo-
nents from different manufacturers is the most critical safety concern in the indus-
try. Indeed, tyre handling and other related tasks also hide risks (­e.g. when using
equipment). However, of concern in this instance is that a small mistake during the
assembly process can result in a catastrophic disassembly of the wheel under approx-
imately 150 psi.
106 Ergonomic Insights

In general, mismatching components is a significant concern because many peo-

ple stand in front of the tyre several times a day. Any mistake can kill them or
somebody nearby. The tyre fitter’s worse nightmare is to work at a mine site opera-
tion with several different OTR wheels from various OEMs and be tasked to change
the inner tyre on a dual wheel assembly while working alone at night, which is very
common across mine sites around the world. Not only are tyre fitters exposed to the
consequence of this hazard but could also be blamed for mismatching components.
As Brady (­2019, ­p. 29) pointed out, ‘­a common view in the mining industry is that
“­human error” plays a substantial role in fatalities [… and] a common term used
in the industry is “­lapses in concentration”’. This can lead to the unfair assump-
tion that tyre fitters choose to get hurt and consciously lose concentration, or they
lapse in concentration, whereas, in reality, the bad design of the wheel and poor
working conditions set the tyre fitters to fail. All these are further aggravated by
the fact that their training focusses on the minimum necessary level of competency
that, however, might not match the level of complexity required by the job demands
(­­decision-making in limited time; basic risk assessment, analysis, and treatment;
planning, etc.).
Following a meeting with some engineers and the safety team on this matter, I
left the room frustrated because there seemed to be almost nothing that could be
done to prevent mismatching components. Even the organisation’s idea of marking
and identifying OTR wheel components could not go ahead because of the potential
damage to the steel, there was a high chance that any attempt to mark critical wheel
components could result in brittle points and, thus, cause mechanical failure. The
seemingly good solution to mark components could become a worse problem.
Still determined to do something to improve safety by design, I found a QLD
Mines Health and Safety Inspector on LinkedIn who had published several papers
on critical risks related to OTR wheels and tyres. After a quick exchange of mes-
sages, we went for a coffee and discussed some ideas on what could be done to
assist in improving safety in the OTR tyre management industry. We realised how
much we shared in terms of frustrations and the desire to do something more tan-
gible to improve the work conditions of tyre fitters. QLD Mines Department had also
done as much as they could to improve the OTR tyre management industry from the
regulatory perspective, particularly by issuing the Recognised Standard 133 and the
Guidance Note 314 for Tyre Wheel and Rim Management.
Both documents had a significant positive impact on the mining industry in
Australia as they provided mining operators with guidelines on how to comply
with minimum safety requirements. However, the design of wheels was still an
inherent risk that could only be addressed if the stakeholders targeted a more influ-
ential reference, the Australian Standards (­AS). The AS 4457.1 Wheel Assemblies
and Rim Assemblies5 was last updated in 2007. It was supposed to be supported by
a committee of experts to collect good practices and feedback from the industry
and keep the document updated. However, the committee was dismantled circa

3 https://­www.resources.qld.gov.au/­_ _data/­assets/­pdf_file/­0 004/­986071/­­recognised-­standard-13.pdf

4 https://­www.resources.qld.gov.au/­_ _data/­assets/­pdf_file/­0 005/­1407785/­­qld-­guidance-­note-31.pdf
5 https://­www.standards.org.au/­­standards-catalogue/­­sa-snz/­m ining/­­me-063/­­as-- ­4457-­dot-­1-2007
Off-The-Road Tyre Management 107

2012, and since then, although two coroner’s ­tyre-related fatal accident reports
in QLD urged for the AS 4457 to be updated, nothing has been resolved (­Barnes,
2006; O’Connell, 2014).
Soon after our meeting, the inspector and I formed a working group with tyre
management experts from all major OTR wheel OEMs and two representatives
from mining powerhouses. Our intention was to standardise the design of the wheel
components, in particular the angles. We also planned to develop a guideline for
marking and numbering wheel components to assist tyre fitters in visually identify-
ing and selecting matching wheel components. The idea was well received by the
group. Everyone was feeling confident that they could finally solve a problem that
had remained unresolved for a long time. We worked together for months until the
proposal to update the Australian Standard 4457.1-2007 was completed.
The proposal was then submitted and rejected for the first time at the end of 2017
and then again for the second time. The team that assessed the proposal told our
group that there was no consensus among the members on the necessity for the AS
4457.1 to be reviewed; no further details and explanations were provided. Despite
the consensus among the experts of the OTR tyre management working group that
changing the Australian Standard was the only solution for the problem of mismatch-
ing wheel assembly components, the team appointed by Standards Australia did not
provide us with any strong arguments to justify their decision to reject our proposal.
There was something very wrong here.
Unfortunately, given that no details were provided about the rejection of our
request to modify a ­15-­year-old standard, we could only speculate on what happened.
Significant changes in the mining industry usually occur only if they are to address
something that can cause serious damage to the reputation of organisations or is
imposed by investors. For example, after two major tailing dam failures in Brazil,
a group of international investors was concerned about the legacy issues related to
the disposal and closure of tailing dams. This forced the International Council for
Mining and Minerals to lead a working group responsible for the development of
the Global Industry Standard on Tailings Management in August 2020 (­Hopkins &
Kemp, 2021). Otherwise, many more ­Brumadinho-like dam disasters (­Rotta et al.,
2020) could have happened across the world.
Admittedly, at the time of writing my chapter, March 2022, the AS 4457.1 stan-
dard is shown as pending revision. However, I am not aware of what changes will
be incorporated. Nevertheless, there is no doubt that the solution for mitigating the
risk of mismatching components requires a substantial investment from the industry
because several OTR wheels would have to be phased out and replaced by better
and safer wheel assemblies. This is a significant undertaking, indeed. However, as
an accident due to a mismatch can affect only one operator and is unlikely to make
cover page headlines, this might not hold political sway to effect change.
As safety professionals, we might underestimate the capacity of industry to
ignore serious problems by using their w ­ ell-known ­blame-­and-shame way of busi-
ness to push things under the carpet (­Pitzer, 1999; Gunningham & Sinclair, 2009;
Tian et al., 2014; Stemn et al., 2019). Ineffective safety actions, such as hanging
‘­safety’ signs on the walls and carrying out a couple of toolbox talks a month, are
valued practices that do not impact operations in an effective manner (­Dekker,
108 Ergonomic Insights

2017). I also underestimate the political and ­power-related interactions that happen
in any industry. I am generally good at working in the sharp end but bad at playing
the ­blunt-end game.

IN HINDSIGHT
The first case demonstrated the importance of empowering people to expose their
ideas in a supportive and psychologically safe environment. It is easy for us to jump
to conclusions straight away and move on to the next issue to be addressed. However,
sustainable solutions can only be created if we pay attention to what workers need to
do their work safely and more effectively.
The second story presented a ­real-world example that good intention to solve criti-
cal risks is not enough. Changing an outdated standard was revealed to be more chal-
lenging than anticipated (­and nearly impossible). This is true when there are more
interests on the line other than making the industry trustworthy and safer. With the
benefits of hindsight, proposing a working group inside Standards Australia may
have been a better strategy. That seems better than the alternative to do nothing and
sit and wait for a major accident to happen so that the standard can be updated in
blood. Only time will tell.

REFERENCES
Barnes, M. (­2006). Inquest into the Death of Peter Whitoria Marshall. Office of State Coroner.
Brady, S. (­2019). Review of All Fatal Accidents in Queensland Mines and Quarries from 2000
to 2019. Department of Natural Resources, Mines and Energy.
Cooperrider, D. L., Whitney, D., & Stavros, J. M. (­2008). Appreciative Inquiry Handbook (­2nd
ed.). Crown Custom Publishing.
Dekker, S. (­2017). The Field Guide to Understanding ‘­Human Error’ (­3rd ed.). CRC Press.
DOI: 10.1201/­9781317031833
Godwin, H. (­ 2020). Mining Supervisor Champions Safety. Otraco. https://­ otraco.
com/­news/­mining-supervisor-champions-safety
Gunningham, N., & Sinclair, D. (­2009). Regulation and the role of trust: Reflections from the
mining industry. Journal of Law and Society, 36, 167–194. DOI: 10.1111/­j.1467–6478
.2009.00462.x
Hassall, M. & Boyle, M. (­2016, August 14–17). Addressing Tyre Risks with Critical Control
Management – A Collaborative Industry Project [paper]. A past forgotten is a future
repeated. Health and Safety Conference 2016 of the Queensland Mining Industry, Gold
Coast, Australia.
Hopkins, A., & Kemp, D. (­2021). Credibility Crisis: Brumadinho and the Politics of Mining
Industry Report (­1st ed.). McPherson’s Printing Group.
Laurence, D. (­2005). Safety rules and regulations on mine sites – The problem and a solution.
Journal of Safety Research, 36. DOI: 10.1016/­j.jsr.2004.11.004
O’Connell, D. (­2014). Inquest into de death of Wayne Macdonald. Office of State Coroner.
Pitzer, C. (­1999). New thinking on disasters: The link between safety culture and risk-
taking. The Australian Journal of Emergency Management, 14(­ 3), 41–50. DOI:
10.3316/­ielapa.392186186255759
Provan, D. J., Rae, A., & Dekker, S.W.A. (­2019). An ethnography of the safety profession-
al’s dilemma: Safety work or the safety of work? Safety Science, 117, 276–289. DOI:
10.1016/­j.ssci.2019.04.024
Off-The-Road Tyre Management 109

Rasche, T. (­ 2019, August 19–22). A Study to Investigate Uncontrolled Tyre and Rim
Disassembly [video presentation]. Working to the future, Health and Safety Conference
2019 of the Queensland Mining Industry, Gold Coast, Australia. https://­qmihsc2019.
evertechnology.com/­conference-session/­cross-border-safety-opportunities/
Rotta, L. H. S., Alcântara, E., Park, E., Negri, R. G., Lin, Y. N., Bernardo, N., Mendes, T. S. G., &
Filho, C. R. S. (­2020). The 2019 Brumadinho tailings dam collapse: Possible cause and
impacts of the worst human and environmental disaster in Brazil. International Journal
of Applied Earth Observation and Geoinformation, 90. DOI: 10.1016/­j.jag.2020.102119
Smith, G. (­2018). Paper Safe: The triumph of bureaucracy in safety management. Wayland
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rims and tyres – Maintenance and repair, Part 1: Wheel assemblies and rim assemblies.
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of incident investigations conducted in the Ghanaian mining industry. Safety Science,
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1). Queensland Mines Inspectorate, Resources Safety & Health Queensland.
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 10 The Human
Factors Practitioner
in Engineering
­Contractor-Managed
Investment Projects
Ruud Pikaar
ErgoS Human Factors Engineering

CONTENTS
Stories to Be Told.................................................................................................... 112
Project Phase 1: Scope Definition...................................................................... 113
Review of Initial Design................................................................................ 113
What Is an Ergonomic Study?....................................................................... 113
What Did We Learn from Scope of Work Issues?......................................... 115
Project Phase 2: ­Kick-Off and Task Analysis.................................................... 115
­Kick-Off........................................................................................................ 115
Operator Workload and Work Organization.................................................. 116
What Did We Learn about the ­Kick-Off Meeting and Task Analysis?......... 116
Project Phase 3: Disappointment ­Phase – Design Review................................. 116
Control Centre ­Layout – Failure!.................................................................. 117
Control Room ­Layout – An Improvement!................................................... 118
Control Room ­Furniture – Success!.............................................................. 118
Work Environment ­Issues – Success or Failure?........................................... 118
What Did We Learn from the Design Review?............................................. 120
Project Phase 4: Bittersweet Phase.................................................................... 120
What Did We Learn from the Bittersweet Phase?......................................... 121
Project Phase ­5 – Document Control................................................................. 121
What Did We Learn about Document Control?............................................ 122
Discussion............................................................................................................... 123
Roles................................................................................................................... 123
Communication............................................................................................. 123
Commitment.................................................................................................. 124
HF Consultancies Are Small Enterprises...................................................... 124

DOI: 10.1201/9781003349976-10 111

112 Ergonomic Insights

Last Remarks.......................................................................................................... 124

References............................................................................................................... 125

Human Factors/­Ergonomics (­abbreviated to HF) is always d­ esign-driven. Dul et al.

(­2012) summarizes this by defining HF as (­1) the scientific discipline concerned with
the understanding of the interactions among humans and other elements of a system
and (­2) the profession that applies theoretical principles, data, and methods to design
to optimize human ­well-being and overall performance. HF practitioners apply their
knowledge in technical and organizational settings. They interpret and integrate the
results of scientific research into the design of complex ­human–machine systems.
At our HF Engineering company, we have a large, although unpublished, database of
nearly 40 years of HF projects related to the process industry, oil and gas, manufactur-
ing, rail and road traffic management, and offshore shipping. In this chapter, we present
a case of a new Floating Natural Gas processing system. It is a huge vessel, which can-
not navigate on its own. It holds several process units, liquified gas storage, and loading
facilities. The process units are supervised and controlled from a control centre, which
looks much the same as onshore control centres in the oil and gas industry.
This project was one of eight oil and gas control centre projects carried out
within comparable organizational settings (­Pikaar et al., 2021). Three of these proj-
ects regarded liquified gas processing and were situated with the same Engineering
Contractor. The project of focus in this chapter was the second one and will be
referred to as the “­Project”. Experiences from the first project will be mentioned,
including our learnings for the next project. I use the term “­we” frequently, as this
type of project is always carried out by a team of several HF consultants of our com-
pany. The team was the same for all three projects.
The project owners (­referred to as “­Company”) were major international oil and
gas companies. The projects were managed by an Engineering and Procurement
Contractor (­EPC). For the first two projects, our company, which employs five
registered senior European Ergonomists (­ Eur. Erg.), was subcontracted by the
Instrumentation and Control System ­sub-Contractor (­ICSC). For the third project,
we were contracted by the EPC. The Project was purchased at a fixed price, based on
approximately 100 days of HF work.

STORIES TO BE TOLD
There are many stories to be told about the Project. I selected several typical stories
about the balance between “­good HF practices” and commercial engineering issues.
What is acceptable for the HF professional? What to do if it is not good enough or
even a bad design, seen from an HF point of view?
Our stories are organized along five project phases:

1. Scope Definition: The scope of work is developed before you commence an

HF consultancy contract.
2. Kick-off and Task Analysis: The k­ ick-off concerns the organization of the
HF contribution, as well as an explanation of what HF is about. The next
step should be a task analysis.
Human Factor Practitioner in Investment Projects 113

3. Disappointment Phase – Design Review: Based on ­task-related knowl-

edge, the initial design will be reviewed. A review inevitably leads to HF
shortcomings.
4. Bittersweet Phase: ­HF-based improvement design proposals, presented in
3D and through Virtual Reality.
5. Document Control: ­Wrapping-up documents and c­ lose-out.

Project Phase 1: Scope Definition

Communication between the EPC or the ICSC and the HF consultant starts with a
Request for Quotation (­RfQ) or Invitation to Bid. Usually, RfQ is not written by HF
experts. RfQ is approved by the Company and accepted by the EPC and ICSC. At
the table of the ­ICSC-buyer, the R
­ fQ-specified scope of work is hardly negotiable
because changing a C ­ ompany-approved document is very difficult. If you want the
contract, you need to comply or at least say that you will do so.
The main interest of the customer is in workplace design and environment.
However, to arrive at an acceptable workplace design, the HF consultants need to
consider operator tasks and workload. One needs to determine or validate the num-
ber of operators and consoles required for safe operations. This will also tell you
how many process graphics are to be expected, as well as the number of screens that
would be needed in the workplace (­Pikaar, 2012).

Review of Initial Design

For our cases, the RfQ requested a review of the initial control centre design, includ-
ing solving any ergonomic problem arising from this review. The initial design is the
result of the ­so-called ­Front-End Engineering Design (­FEED) phase at the EPC. In
our cases, there had been no HF input during FEED. EPCs tended to rely on ­copy–
paste from earlier projects and, if available, Company ergonomic guidelines. If we
were to find several ergonomic ­design-related issues, there would be lots of work to
do. Remember these projects are contracted at a fixed price. Getting an additional
budget is difficult and ­time-consuming. Hence, it may be tempting not to report all
issues arising from a review.
For the first project, although promised otherwise, it turned out that there was
no layout drawing of the control centre. The control room (­CR) area was an empty
space. Instead of doing a review, we ended up with a full design cycle. This is not
necessarily bad because you can introduce a splendid ergonomic design. However, it
may take additional time. Learning from this, we offered more days of Project work
for the review. Fortunately, in this case, a conceptual design of the room layout was
available, however, not based on any ergonomic guidelines.

What Is an Ergonomic Study?

Usually, the RfQ requires the deliverable “­ergonomic study”. In the first project,
there was no further description of “­ergonomic study”. During clarification, we sug-
gested referring to the HF design steps specified in part 1 of ISO 11064 Ergonomic
design of control centres (­­1999–2013). Surprisingly, for the Project, the RfQ included
this suggestion. We considered this to be a small success!
114 Ergonomic Insights

­FIGURE 10.1 Five phases of HF design. (­Adapted from ISO ­11064-1.)

Part 1 of ISO 11064 specifies in section 5 a “­Framework for an ergonomic design

process of control centres”, consisting of the following phases (­­Figure 10.1):

A. Clarification of purpose, context, resources, and constraints of the project.

B. Analysis and Definition: This includes a functional analysis and allocation,
job design, and validation of obtained results. Unfortunately, the text doesn’t
clarify how and when a task analysis based on interviews and observations
of operators should take place. In ISO ­11064-Part 2, such a task analysis is
presented as being mandatory because a good insight into operator tasks is
essential for any design.
C. Conceptual Design: This consists of two steps: (­1) the design of a concep-
tual framework for the CR and (­2) review and approval of the conceptual
design. The design concerns CR layout, routing, workplace layout, instru-
mentation, a communication matrix, visual tasks, etc.
D. Detailed Design of operator consoles, fixed and loose furniture, arrangement/­
mounting of instrumentation, cabling, and process graphics. This step also
includes the specification of environmental requirements.
E. Operational Feedback for evaluation purposes after commissioning.

Notably, it is a common practice that process graphics/­interaction design is not in the

HF scope. ICSCs are convinced of being competent in this HF aspect, but often they
do not comply with basic interaction guidelines (­Pikaar, 2012).
Also, during the development of ISO 11064, I recall significant discussions and
some confusion about Phase B Analysis and definition. The interpretation of “­task
analysis” is ambiguous. Does it include the allocation of tasks or is it merely acquir-
ing knowledge about actual tasks? Functions and function allocations are defined on
a higher level of abstraction and may be related to determining the level of automa-
tion of the production system.
Human Factor Practitioner in Investment Projects 115

Anyhow, in practice, the use of functions instead of tasks doesn’t work for an
engineering team having a limited understanding of HF because it is too abstract.
Therefore, we always start with a task or situation analysis, meaning what is hap-
pening in the existing or a comparable control centre. Next, we draw conclusions
and specify requirements for operator jobs and work organization in the new system.
These requirements are input for Phase C. At this point, we perform a task allocation
to design jobs and, thus, workplace requirements to accommodate those jobs. Still,
this is not an easy approach because technical engineers and project managers usually
expect that an HF study is, would, or should be limited to Phase D “­Detailed design”.

What Did We Learn from Scope of Work Issues?

The introduction of the ISO 11064 five phases was successful. It landed in the RfQ
for this and other projects. Did this approach work for the Project? Hardly, because it
remained difficult to convince the engineering team of the necessity of a systematic
task allocation, work organization design, and job design because “­Operator jobs are
the Company responsibility. Just give us a detailed workplace design specification”.
In the first project, two experienced former shift supervisors participated in the
project team. In the Project, two commissioning coordinators participated. In both
cases, they were our source for ­task-related information and provided valuable feed-
back on our proposals and recommendations. They reported to the Company, not to
the EPC. Consequently, we could not support them during meetings at the Company
level in convincing management. That was a task in which they didn’t always suc-
ceed. Commitment to HF is a key issue, particularly at project lead and higher man-
agement levels at an EPC and the Company. Nowadays, we put the commitment issue
high on the agenda of the RfQ clarification and the ­k ick-off meetings.

Project Phase 2: ­Kick-Off and Task Analysis

The project team consisted of an EPC project lead, the person responsible for the
ICSC project, two HF consultants, individuals from several engineering disciplines,
and several Company representatives.

­ ick-Off
K
The ­kick-off meeting was organized in three ­half-day parts. Part one was dedicated
to getting to know the project team. It included an explanation of HF guidelines,
design approach, and scope of work. Part two was dedicated to acquiring knowledge
of the processes to be supervised and controlled, operator jobs, and work organiza-
tion. For the Project, we had to rely on our own understanding of the process units
because for this greenfield project there were no experienced operators available.
Justifiably, the Company might have considered it too early to think about staffing as
it would take another three years before the vessel becomes operational.
The third part of the meeting regarded a lengthy explanation of the document con-
trol principles and how to use the document issuing software. During the presentation,
we did not really understand the complexity of the document control system. During
the project, we relied on the ICSC for assistance. Notably, during all progress meetings,
presence varied. Many participants were only available when their own specialism was
116 Ergonomic Insights

tabled. Consequently, it was difficult to share our HF expertise effectively and reach a
consensus on the integration of design inputs from different disciplines.

Operator Workload and Work Organization

We were concerned about the allocation of process units to operator positions.
However, the project team refused to understand the importance of task analysis for
estimating operator workload. We managed to get an overview of the operator roles
and work organization. Operators would be trained for only one of the following
work positions:

• 1 operator + 1 supervisor for subsea production.

• 2 process operators + 1 supervisor for compressor units and utilities
• 1 marine operator + 1 supervisor for offloading and all marine activities

We made workload estimates based on our expertise. As a result, we expected over-

load problems for the marine operator, amongst other things, because this person
had to handle two very different types of instrumentation: maritime instruments and
process supervision. Also, the work organization looked slightly odd. One supervi-
sor for each operator position! So, what would be the supervisory role? Our concerns
were discussed, and some changes were effectuated in the allocation of process units
to work positions.

What Did We Learn about the ­Kick-Off Meeting and Task Analysis?
It should be clear who is responsible for leading the team, running meetings, taking
minutes, and drawing conclusions and/­or making decisions. At first, the EPC lead
had no intention of chairing the meeting and left it to us. That did not work. Being
a s­ ub-­sub-contractor, you don’t have much impact on the format and outcomes of a
meeting. Also, being chair and designer/­consultant at the same time is difficult. In
the Project, the ICSC responsible for the HF contribution took over, which was help-
ful and had a better impact. The ICSC has better possibilities to escalate issues. A
minor drawback was caused by several participants speaking a native language other
than the project language. Finally, the Project strengthened our idea that one needs
a certain amount of understanding of the technical processes involved to fill in the
blanks about operator jobs and determine role demands.

Project Phase 3: D
 isappointment ­Phase – Design Review
The CR was a rectangular room (­9 × 21 m²), with four operator consoles. Corridors
were projected on the left and right sides as indicated in ­Figure 10.2.
The FEED design of the control centre was checked against ISO 11064 (­­1999–
2013). To mention a few requirements:

1. Adequate space for its users, workplaces, and instrumentation. As a rule

of thumb, each console position needs ­25–50 m². In general, each opera-
tor position should also facilitate workspace for a second person during
­off-normal process conditions, for training purposes, and so on.
Human Factor Practitioner in Investment Projects 117

­FIGURE 10.2 F
­ ront-End Engineering Design (­F EED) layout design of the control centre.

2. CR access should be situated in front of the user(­s). Thus, operators have

visual control over who is entering/­leaving the CR, and it is less disturbing
than locations that are not in their field of view.
3. Operator positions having frequent communication with each other should
be located close to each other and preferably within each other visual fields.
This enables quick and reliable ­face-­to-face communication.
4. ­Non-­process-related communication shall not disturb operations in the CR.
Staff who are not part of the operational 24/­7 team may be tempted to use
the CR for meeting purposes and acquiring information. Process operators
need a quiet workplace to be able to concentrate on their cognitive tasks.
5. Operator workload should be on an acceptable level, not too much and not
too little work. Operator workload may be estimated based on the num-
ber of controlled process variables, the expected rate of o­ ff-normal signals,
communication with field operators, and thus the number of field operators,
and communication with colleagues in the CR. The last variable can be
related to the number of process flows between process units allocated to
each operator position (­Pikaar, 1992).

Control Centre ­Layout – Failure!

Both entrances to the CR as well as walking routes were at the operators’ back. The
corridor between CR and Emergency Control Centre (­ECC) blocks quick and easy
communication between both areas. Assuming the need for good communication
in ­off-normal situations, direct visibility, and easy access is both recommended and
best practice. We recommended removing both corridors to restructure routing and
reduce operators’ hindrances. Also, this would add some additional space to the CR
and create direct communication lines between ECC and CR.
118 Ergonomic Insights

Based on our experience in ship design, we expected that these steelwork changes
could be implemented without problems. It could even be done after steelwork con-
struction. However, the shipyard refused to engineer changes, threatening large addi-
tional costs due to construction delays. The communication shown below is typical
for this type of issue.

HF Professional: Did the project consider direct communication (­visual contact)

between ECC and CR?
Company Operations: that was not implemented due to layout constraints as reported
by CONTRACTOR. It does require careful consideration as to what com-
munication and information are required in the ECC for information from
the CR. Please review and recommend. Replica screen for process graph-
ics at ECC in order to not interrupt the distributed control system (­DCS)
Panel Operator may be an option.
Contractor: Consideration was given, but due to other design requirements, the cur-
rent configuration was adopted.

Certainly, refusal to consider recommendations can happen. However, we were also

expected to remove our recommendation from the ergonomic study report. If not,
there might have been no report approval. I will come back to this “­integrity issue”
in the section on document control.

Control Room ­Layout – An Improvement!

FEED documents specified nine workstations, suggesting a maximum number of
nine operators. The difference between four and nine work positions raised ques-
tions. Maybe, this had to do with the role of supervisors. Frequent ­face-­to-face com-
munication between supervisors and operators was expected. Also, the supervisor’s
office was rather small (­21 m²) for three desks. Hence, we suggested creating super-
visor workstations next to each CR console (­­Figure 10.3). Nonetheless, the role of the
supervisors was never clarified to us.

Control Room ­Furniture – Success!

The initial CR layout (­­Figure 10.2) showed n­ on-adjustable furniture without ade-
quate legroom below the desks. The furniture was preordered by the ICSC at their
tender for the project three years earlier! It was easy to convince the ICSC about this
issue. However, this modular worktable system was part of the ICSC purchase order.
They needed to go to the EPC with a change order request. Internal ICSC, EPC, and
Company decisions took several months. Meanwhile, we developed a ­custom-built
design, which was accepted in the end. A valuable tool to achieve success has been
our 3D images of the CR design.

Work Environment ­Issues – Success or Failure?

As registered HF professionals we know our limitations. For example, we are
competent to develop a lighting plan, but for other environmental topics, we may
only check engineering results for compliance with guidelines and best practices.
Reverberation time is an indicator of the acoustic quality of rooms. Guidelines for
Human Factor Practitioner in Investment Projects 119

­FIGURE 10.3 HF proposal for the control centre layout.

office environments aim for <0.50 seconds. Best practices for CRs suggest doing
better than this, preferably <0.45 seconds. A reliable estimate can be made using
Sabine’s equation (­Schomer & Swenso, 2002). During the review, we noticed in the
noise philosophy document that a reverberation time >1.0 seconds was required for
the CR. This might have been a typing error. So, we asked a question about this but
got no reply.
The real problems started after we recommended additional ­noise-absorbing
measures for the CR, based on an estimated reverberation time of 0.63 seconds.
Apparently, engineering didn’t like this recommendation. They used every trick in
the book to delay progress, such as not responding within a reasonable time, postpon-
ing meeting dates, not showing up, asking irrelevant return questions about acoustics,
and finally flatly refusing collaboration. Although frustrating, this was not uncom-
mon, and therefore, relatively easy to accept. However, we were also urged to remove
our recommendation from the ergonomic documents to get final approval.
Regarding the lighting plan, the above situation was repeated. The reason we
developed competence on this topic is the utmost importance of ­glare-free lighting
at ­multi-screen workstations. The shipyard provided a product catalogue of a local
vendor. The catalogue included outdoor and navigation lighting, workshop lighting,
bedside lamps, etc., but no suitable fixtures for offices or m
­ ulti-screen workplaces.
We explained what characteristics were needed and asked for relevant datasheets
or data files for modelling a light plan. After several delays, we received the same
catalogue three times.
Ultimately, approved by the ICSC, we developed a lighting plan based on the
products of a marine lighting vendor from Norway. Obstruction at the yard became
fiercer, including attempts to disapprove reports and payment milestones. What
seemed to happen is that the shipyard was buying fixtures from a local vendor.
They mounted the fixtures at the locations indicated in the H ­ F-approved light plan,
120 Ergonomic Insights

disregarding light source specifications. Glare issues would be expected, but it was
impossible for us to verify. Although writing this chapter a few years after our activi-
ties for the Project, the vessel is not yet operational.

What Did We Learn from the Design Review?

According to our interpretation of the Code of Conduct for European Ergonomists,1
we should report HF issues, even for ergonomic aspects outside the Scope of Work.
In the Project, this was not appreciated by those responsible at the main contractor.
It is understandable that engineers don’t like comments on their work, but the lack
of communication between HF and engineering was frustrating for us. We assume
that more ­face-­to-face communication might have helped, notwithstanding the lan-
guage barrier. After several incidents, we stopped our t­ ime-consuming efforts trying
to improve. It was also clear that the document control system can have an impact
on the EPC behaviour. We learned we should never attempt to change an approved
document. This is also frustrating but a characteristic of E ­ PC-managed investment
projects.

Project Phase 4: Bittersweet Phase

After the review, a redesign of operator consoles and CR layout was undertaken.
Amongst others, it resulted in a dedicated detailed design for the operator consoles.
We introduced separate furniture for office tasks, printers, manual storage, and inte-
rior design (­i.e. colours, materials, and finishes), including additional ­sound-absorbing
materials. The results were presented in 3D images. ICSC and the Company were
happy.
We recommended reducing the number of process screens on the consoles from
typically 12 per work position down to ­6 –8. We had no doubt that this would be
possible by optimizing the content of the process graphics (­Pikaar, 2012). Our effort
failed, but that was to be expected looking at CR solutions on the market with large
arrays of tiled screens and many process graphics which, of course, determines the
ICSC revenues. Of course, this topic was not in our scope.
For the marine console, the situation was different. Engineering responsibility
was divided into four different disciplines: ICSC (­processing units), communication,
CCTV system, and radar. The total number of screens of different makes, sizes,
and interactions was considerable. We counted 10 process screens, CCTV, and radar
screens, two large annunciator panels, and separate instrument bays for maritime
communication equipment. There was a ­long- and ­short-range radar and an expen-
sive very h­ igh-resolution CCTV camera system for large distance recognition of
approaching vessels. Both radar systems were to be installed as a backup for the
CCTV in case of bad weather.
There was no clear idea about the operator tasks. Why was all this stuff needed
since the vessel was anchored and would not navigate at all? Could one operator cope
with all systems? From our point of view, it was not acceptable and possibly a safety
risk. Initially, the EPC asked for our assistance in this matter. A purchase order

1 https://­eurerg.org/­­wp-content/­uploads/­2021/­11/­­CREE-­code-­of-conduct.pdf
Human Factor Practitioner in Investment Projects 121

change glowed on the horizon. However, it appeared that our recommendations were
not acceptable to the shipyard. All further communication ended abruptly.

What Did We Learn from the Bittersweet Phase?

A major part of an ergonomic study is the actual design of the CR and workplaces.
This is a rewarding activity, always exploring possibilities to develop a unique and
optimal result. However, HF is not a leading topic. Hence, you need to accept restric-
tions and compromises. Overall, we were happy with the result. Moreover, the ICSC
was proud of the result. The bigger picture, however, is challenging. How to convince
the stakeholders of the importance of, for example, a task analysis, an ­HF-inspired
interaction (­graphics) design, workload assessment, lighting, and acoustics? We
believe that we could have done better regarding communication, provided the main
contractor would allow or facilitate this.
Unfortunately, there is not much more to say about this phase. During the commis-
sioning of the vessel and its process installations, HF is not present. If we are lucky,
pictures appear on the internet about a successful naming ceremony or an official
handover of the vessel to the Company. We could find pictures of the CR for the first
project from the official opening ceremony. Organized operational feedback is seldom
part of an HF Scope of Work. We tried many times to introduce this in the bidding,
but generally, companies don’t want to spend money on this. There is no doubt that
feedback would be useful, and it is part of all theoretical design approaches. Pikaar
and Caple (­2021) offer recent insights into why case material is seldom published.

Project Phase ­5 – Document Control

One could say that document control is a project internal way to fill in operational
feedback. From an HF point of view, documents need to clarify (­1) why specific solu-
tions have been adopted and (­2) what dependencies exist between workplace layouts,
viewing distances to screens, readability, and the environment (­e.g. light and ventila-
tion). For these reasons, we try to integrate related factors into one report. Thus, a
report on workplace design and CR layout could be one Ergonomic Study report.
Another report addresses related environmental aspects (­i.e. a focus on ceiling design).
However, in the first project, the scope of work specified 14 documents, including
a document listing the documents that would be produced. Each document would
require three submissions (­1) for review, (­2) for approval, and (­3) final. Feedback
from all stakeholders should be received within three weeks. In practice, comments
came late. During the first project, documents also needed to be translated. Here, the
ICSC took care of the translation, but we also learned that you need a certified trans-
lation agency, specialized in the terminology used in engineering and the particular
type of industry.
For the Project, we were able to agree on seven deliverables, a 50% reduction
compared to the first project; it looked like a success! These were:

1. Ergonomic Study report: A full description of the CR design.

2. Furniture descriptive notice: A detailed furniture specification, ready for
the Invitation to Bid to furniture vendors.
122 Ergonomic Insights

3. Integrated ceiling design about lighting, ventilation, and noise control mea-
sures: It is usually issued separately, after approval of the CR layout and
workplace design. Notably, this is a challenge because engineering requires
this in an early project phase.
4. Wall and floor covering: This document could have been avoided by com-
bining it with document 3.
5. CR Drawing 2D
6. CR Drawing 3D
7. Room Drawings: 2D drawings for each of other rooms in the Control Centre.

We believe that an ergonomic study report should be a “­living” document, updated

at each design step based on feedback from users. The idea of living documents
implies informal feedback before formal submission. For documents No 5, 6, and 7,
we intended to deliver the original 3D CAD file and sets of images. This idea did not
fit in with the requirements of the document control department. The artefacts had to
be written to undergo the document control process. Based on our experience from
the first project, the Ergonomic study report also included an introductory statement
(­disclaimer): “­We would like to emphasize that at this phase of an HF contribution,
we give our professional opinion. Our comments are based on generally accepted
Human Factors knowledge, guidelines, and best practices. Our comments may not
be in line with the current design. In those cases, please consider the comments
open-mindedly”.
The third project was managed differently and more proactively. The number
of reports was reduced to four during discussions on the RfQ/­Scope of Work. The
reports and recommendations were appreciated. Document control was efficient,
which can be attributed to the proactive EPC project management. In fact, here the
living document approach came to life, resulting in only two formal revision cycles.

What Did We Learn about Document Control?

Document control is typical for this type of industry. Document controllers are
powerful. However, the procedures do not easily allow for an integration of design
aspects. In the Project, the recorded amount of work on document control was >40%
of the total HF job. The procedures were ­time-consuming. Comments from different
stakeholders did not become available at the same time and were not managed prop-
erly. Company comments were always late, and there was no effort to solve contra-
dictory comments from different stakeholders. The Company and the EPC disagreed
on several ­HF-related issues. However, the document control process didn’t allow
us to explain and discuss these issues. In practice, the three revision cycles became
2 × 3 cycles.
As mentioned earlier, integrity issues occurred, which had an impact on the
document ­ control–related work. In case HF recommendations were not imple-
mented, we were expected to remove them completely from the report(­s). Also, we
were urged to describe the final design according to stakeholder decisions, as if it
was an ­HF-approved result. It is difficult to tell whether this situation is typical for
­EPC-managed projects or had to do with the EPC lead and/­or other persons in the
Human Factor Practitioner in Investment Projects 123

engineering team. Notably, document control in the third project approximated 20%
of our total work efforts.

DISCUSSION
“­Why did they hire HF professionals, if there was no intention to change an initial
design?”

Roles
After reading this chapter, you might ask the question above. Clearly, our expecta-
tions on both the engineering process and HF content contributions didn’t match with
the ideas of the EPC. Partially, the mismatch has to do with different roles the HF
consultant may have in large industrial projects. Without claiming scientific proof, I
suggest the following different roles for HF consultants in large investment projects
instead of cramming an ergonomic study in an E ­ PC-managed project.

• Company HF consultant, preferably before FEED

This role provides a powerful position. Our company has years of experi-
ence in this role, and you can read several of our case studies (­Pikaar, 2007).
Typically, this contribution takes place at and/­or even before the FEED
phase of a project. There is large freedom in design. The RfQ and/­or Bid is
based on mutual agreement on the HF activities needed.
• HF review consultant
This role is about an independent validation and verification of an HF
design developed by others. This activity is mandatory in Norwegian oil
and gas projects (­Johnsen et al., 2016; Pikaar et al., 2016) and can be man-
dated by Company rules. The consultant is contracted by or on behalf of
the Company. The job is straightforward. Recommendations are taken seri-
ously; it is a formal review! Costs can be calculated easily, and a ­fixed-price
purchase order is no problem.
• Detailed HF engineering
A lot of HF engineering must be done after the FEED phase when free-
dom in the design is limited. The HF consultant is part of a much larger
team responsible for the final control centre implementation. Summarising
the above experiences from the three projects, one needs to fight for results
within the fixed budget.

Communication
At the time we received the RfQ for the first project, we didn’t have much experience
with the EPC and subcontracting settings. We were wrong in thinking that we knew
the business. Communication, document control, a large multidisciplinary team, and
all sorts of formalities took more time than expected. For the Project, we were aware
of the risks involved but, nevertheless, our bid was in fact far too low. So, we won
the bid but had to be careful about spending too much time, possibly unintentionally
124 Ergonomic Insights

at the cost of communication. Communication was also hampered by travelling dis-

tances, different cultures, and language barriers.

Commitment
The success of a project also depends on the customers’ understanding of HF. In
cases of high customer HF standards, good results can be achieved. When HF knowl-
edge is limited, achieving good results requires an additional effort for explaining
HF’s background and, of course, an interested audience.
Tightly related to customer HF standards is management commitment. If a com-
pany is purchasing the HF contribution, commitment, generally, is high, and gener-
ous funding is available. If the EPC or a subcontractor is responsible, commitment
may be low as, “­We must do an ergonomic study because the company is asking for
it (­or we are obliged to apply ISO 11064). Please keep it simple and reduce costs”.
Hence, we learned two things. First, find out about commitment before starting the
project, and second, accept more reluctantly suboptimal outcomes. We found this
difficult.

HF Consultancies Are Small Enterprises

We are a small, specialized HF group. Actually, there are no large dedicated HF
enterprises worldwide. If the Company and/­or EPC has a low HF standard, only aim-
ing for compliance with minimum requirements, there are two options. The first is to
comply with their level of understanding and accept the risk of integrity issues. The
second option is to reject the job. However, you may need the job!
According to my experience, the full scope and potential of HF are not always
recognized in large investment projects. Hence, it would be helpful if the HF com-
munity could do more to promote the benefits and applications of HF. According to
Pikaar and Caple (­2021), projects missed substantial benefits because of a lack of
commitment to HF.

LAST REMARKS
This case was about contributing to a control centre project during the detailed engi-
neering phase. The impact of the HF contribution clearly depends on the project
phase. There are better opportunities to integrate HF during earlier project phases.
In detailed engineering, HF is only a small part of the job; you are a minor player.
Others are not too happy to change their work or even to spend time getting to know
something about HF.
In the Project, some typical events were probably more visible than usual. In
some instances, integrity issues arose, such as the request to delete recommendations
against professional responsibilities. This instance may not have been fully represen-
tative, but it shows the effects of some underlying processes, such as project leader-
ship, communication, and the impact of document control systems.
Remember, HF is not about simply adding a nice touch, nor about the fulfilment
of minimum legal requirements. HF is about the integration of the Human Factor in
the design. This requires a commitment by project stakeholders, as well as good and
extensive communication.
Human Factor Practitioner in Investment Projects 125

REFERENCES
Dul, J., Bruder, R., Buckle, P., Carayon, P., Falzon, P., Marras, W. S., Wilson, J. R., & van der
Doelen, B. (­2012). A strategy for human factors/­ergonomics: developing the discipline
and profession. Ergonomics, 55(­4), 377–395. DOI: 10.1080/­00140139.2012.661087.
https://­www.sintef.no/­globalassets/­upload/­teknologi_og_samfunn/­­sikkerhet-­og-palitelighet/­
prosjekter/­lyselng/­criopreport.pdf
ISO 11064. (­2000–2020). Ergonomic Design of Control Centres – Multi-Part Standard.
Geneva, International Organization for Standardization.
Johnsen, S. O., Bjørkli, C., Steiro, T., Fartum, H., Haukenes, H., Ramberg, J., & Skriver, J.
(­2016). Criop: A Scenario Method for Crisis Intervention and Operability Analysis.
Sintef Report A4312. Trondheim. Pikaar, R. N. (­1992). Control room design and sys-
tems ergonomics. In: Kragt, H. (­ed.). Enhancing Industrial Performance: Experiences of
Integrating the Human Factor. Taylor & Francis, 145–164.
Pikaar, R. N. (­2007). New challenges: Ergonomics in engineering projects. In: Pikaar R. N.,
Koningsveld, E. A. P., & Settels, P. J. M. (­eds.). Meeting Diversity in Ergonomics.
Amsterdam, Elsevier, 29–64.
Pikaar, R. N. (­2012). HMI conventions for process control graphics. In: Proceedings of the
18th IEA World Congress on Ergonomics. Recife, Brazil. Work, 41(­suppl 1), 2845–
2852. DOI: 10.3233/­WOR-2012-0533-2845.
Pikaar, R. N., & Caple, D. C. (­2021). Challenges to engaging human factors/­ergonomics
practitioners to publish and present case studies. IISE Transactions on Occupational
Ergonomics and Human Factors, 9(­2), 67–71. DOI: 10.1080/­24725838.2021.2006361.
Pikaar, R. N., de Groot, N., Mulder, E., & Landman, R. (­2021). Cases of human factors engi-
neering in oil & gas. In: Nancy L. Black, et al. (­eds.), Proceedings of the 21st Congress
of the IEA, Volume III: Sector Based Ergonomics. Springer Verlag, 42–49. DOI:
10.1007/­978-3-030-74608-7_6.
Pikaar, R. N., DeGroot, N., Mulder, E., & Remijn, S. L. M. (­2016). Human factors in control
room design & effective operator participation. In: Proceedings SPE Intelligent Energy
International Conference and Exhibition. Aberdeen, Society of Petroleum Engineers
(­SPE).
Schomer, P. D., & Swenson, G. W. (­2002). Electroacoustics. In: Middleton, W. M., & Van
Valkenburg, M. E. (­eds.), Reference Data for Engineers (­9th ed.). Newnes. DOI: 10.101
6/­B978-075067291-7/­50042-X.
 11 Deciphering the
Knowledge Used by
Frontline Workers in
Abnormal Situations
Christopher M. Lilburne and Maureen E. Hassall
University of Queensland

CONTENTS
Preventing the Worst............................................................................................... 130
The Analysis Journey.............................................................................................. 131
Traditional Decision Ladder Analyses............................................................... 131
Modified Decision Ladder Template.................................................................. 133
DeciMap.................................................................................................................. 134
Concluding Reflections........................................................................................... 136
References............................................................................................................... 138

In the oil and gas industry and many other ­high-hazard work domains, frontline
workers are tasked with detecting and addressing abnormal process deviations to
maintain safe and efficient operations. These tasks are critical since, when not prop-
erly addressed, abnormal situations can rapidly escalate into catastrophic events such
as the BP Texas City Refinery explosion which killed 15 workers (­U.S. Chemical
Safety and Hazard Investigation Board, 2007), the Tesoro Anacortes Refinery explo-
sions which killed seven workers (­U.S. Chemical Safety and Hazard Investigation
Board, 2014), and the Soma mine explosion in 2014 in which 301 workers lost their
lives (­Düzgün & Leveson, 2018). Major accidents are still occurring and reoccurring
across ­high-hazard industry sectors resulting in lost lives, significant injuries and/­or
illnesses, environmental harm, and asset damage. Additionally, there are reputa-
tional, legal, and social issues for individuals, corporations, and governments.
This topic is of much interest to us, who hail from the ­high-hazard industries.
Chris worked in the oil refinery industry for nearly 10 years and has had roles as
a process and process safety engineer prior to working in Human Factors and
Ergonomics (­HFE). Maureen has worked in the process, mining, and manufactur-
ing industries for many decades. We both have much experience responding to inci-
dents both operationally and as investigators and have delivered projects to attempt
to address reoccurring incidents; we are passionate about eliminating ­work-related

DOI: 10.1201/9781003349976-11 127

128 Ergonomic Insights

fatalities and catastrophes. From our experiences when incidents occur, including
near misses, incidents, or major catastrophes such as those listed above, investigators
often uncover gaps or mismatches in workers’ knowledge. These “­knowledge gaps”
are commonly associated with a breakdown in the ability to diagnose the system
state and/­or respond in the manner required to mitigate disastrous outcomes. Thus,
recommendations from investigations are often framed in terms of improvements
to knowledge transfer, capture, application, and storage. Prominent examples come
from the United States and the Netherlands. While they are extracts from very large
investigations, their ­k nowledge-based findings are enlightening.
For example, as part of the investigation into the BP Texas City explosion, the U.S.
Chemical Safety and Hazard Investigation Board (­2007) identified that “­the opera-
tor training program was inadequate…” (­­p. 23) and recommended BP “­Improve the
operator training program …” (­­p. 215). When investigating the 2014 Shell Moerdijk
reactor explosions, the Dutch Safety Board (­2015) found that “­The Panel Operators
and the Production Team Leader were supposed to use their knowledge and experi-
ence of this start-up process to adjust the gas and liquid flows, as needed. However,
they lacked this experience” (­­p. 37). More recently, when investigating the DeRidder
Paper Mill explosion, the U.S. Chemical Safety and Hazard Investigation Board
(­2018) found that “­numerous operators demonstrated a general lack of knowledge
about the tank, its role in operations, or hazards that it posed” (­­p. 77) and recom-
mended the company “­provide workers with periodic training to ensure they have an
understanding of all process safety hazards applicable to…” (­­p. 89). There are many
other similar examples publicly available in investigation reports.
The quotes, which are not intended as critiques, provide some detail as to what
knowledge was lacking. However, what are missing are specifics of what knowledge
is required to successfully manage a similar abnormal situation in the future and
how this knowledge should be best conveyed to workers so it will be retained and
applied when required. From our experience in leadership and engineering roles, we
have found that implementing recommendations that tend on the side of generality
can be frustrating as they do not convey the specific knowledge that needs to be
intuitive or available for quick reference by those responsible for hazardous systems
or processes. Depending on the investigation techniques employed, it is possible that
more specific recommendations cannot be generated, often making it hard for a typi-
cal plant manager, engineer, investigator, designer, or operator to define what “­good”
looks like.
Driven by our passion to eliminate fatality and catastrophic events, we set out
to discover what good might look like. We investigated occasions where frontline
operators have successfully arrested or managed a sequence of events before signifi-
cant harm occurred. Our study focussed on successful outcomes as we believed it
might be useful to understand the various conditions and preconditions that support
personnel to identify, diagnose, and respond to abnormal situations. We thought that
capturing such behaviour may lead to insights that allow more effective responses
beyond revealing knowledge gaps after adverse events. The “­human as hero” has
been addressed previously by Reason (­2008) and others who describe how people can
use their knowledge and experience to adapt and improvise to successfully manage
complex systems and situations (­e.g. Jamieson & Vicente, 2001; Rasmussen, 1974;
Deciphering the Knowledge Used by Frontline Workers 129

Rasmussen, Pejtersen, & Goodstein, 1994; Woods, Dekker, Cook, Johannesen, &
Sarter, 2010; Woods & Hollnagel, 2006).
Several seminal case studies also highlight where frontline personnel have
successfully prevented disasters by identifying and solving novel problems in
real time. One example is the US Airways Flight 1549 that was ditched in the
Hudson River in 2009 (­New York, U.S.). In this instance, “­the professionalism of
the flight crew members and their excellent CRM [Crew Resources Management]
during the accident sequence contributed to their ability to maintain control
of the airplane, configure it to the extent possible under the circumstances,
and fly an approach that increased the survivability of the impact” (­National
Transport Safety Board, 2010, ­p. 91). Similarly, during the Apollo 13 event, disas-
ter was “­averted only by outstanding performance on the part of the crew and
the ground control team which supported them” (­National Aeronautics Space
Administration, 1970, p. ii).
Our hypothesis that understanding success is important when responding to
adversities is further supported by the work of Rasmussen et al. (­1994) and Hollnagel
(­2014) who assert that success comes from ensuring that things go right rather than
solely focusing on preventing failure. In short, we sought to answer the question
“­What knowledge do frontline workers need to successfully manage ­high-risk activi-
ties?” by seeking to answer the question, “­What knowledge do frontline workers use
to successfully control ­high-risk work?”
To answer our question, we launched an HFE research project to explore the
­decision-making and actions of frontline workers in an operating oil refinery. Specific
organisation was chosen as Chris had previously worked in the industry which meant
that experience with the technology and processes as well as professional connec-
tions within the company help to gain access to operators. If followed that Chris
was able to facilitate the interview discussions and he spoke the “­language” and
understood the context and significance of the events being discussed by the opera-
tors. This allowed Chris to ask questions needed to gain an understanding of the
knowledge that underpinned how workers successfully resolved ­real-world, abnor-
mal situations that otherwise might have been catastrophic. To help elicit detailed
information about operator ­decision-making, we chose to structure the interviews
using the Critical Decision Method.
The Critical Decision Method is a s­ emi-structured interview strategy designed to
elicit detailed information from ­decision-makers retrospectively about ­non-routine
events (­Hoffman, Crandall, & Shadbolt, 1998; Klein, Calderwood, & MacGregor,
1989). The Critical Decision Method follows several standard “­sweeps”:

1. Identify a suitable event

2. Interviewee describes the event uninterrupted
3. Interviewer identifies and probes one or more key decision points (­Where?
Why? How? etc.)
4. Hypothetical questions are asked. For this exercise, two standard questions
were:
a. How would a novice have performed?
b. What would help in a similar or identical future situation?
130 Ergonomic Insights

Chris conducted these interviews with oil refinery operators over the course of about
four months to cover different operational shifts in each trip. Operators were pro-
vided with an information pack prior to the visit. About half a day was dedicated to
each visit and the individual interviews took between 30 minutes and 1 hour each.
Preparation involved reading other Critical Decision Method interview research and
conducting practice interviews with colleagues who were not involved in this work.
Following each refinery visit, there was a debriefing between us, the authors of this
chapter. Overall, ten volunteer refinery operators were interviewed, and we analysed
the data related to 11 discrete events.
The debriefing process proved beneficial to both of us. It allowed Chris to review
and reflect on the process, the event, and the insights that were being elicited. It also
allowed Maureen to understand the range of events being discussed and the level of
detail being captured. It proved to be a useful check to make sure that the approach
being used was delivering the responses and information that could be further ana-
lysed to answer the question “­What knowledge do frontline workers use to success-
fully control ­high-risk work?”
Through a specific case below we describe the analysis tools used, including the
original and modified versions of the Decision Ladder template and a newly devel-
oped tool called DeciMap.

PREVENTING THE WORST

An oil refinery field operator with more than 20 years’ experience was nearing the
end of his ­12-hour shift. He was walking back to the central control room following
final field checks when he noticed that the seal of a running pump had failed. The
pump was pumping ~270°C hydrocarbon and the leak had begun forming a flam-
mable vapour cloud, which represented an extreme hazard. The operator’s significant
knowledge of the plant meant that he was able to instantaneously identify the leaking
pump, the material leaking, and the associated hazards. Critically, the operator also
knew that this situation was unfolding approximately 15 m away from a fired heater.
The presence of the heater was a significant ignition source that could detonate the
vapour cloud. Around this time, a second field operator also attended to the situation.
As the second operator was not called by the first operation, he most likely attended
by chance or because he could hear the commotion from nearby. At some point
during the initial diagnosis, one of the attending operators radioed into the central
control room to report the situation.
Immediately, the two operators worked together to isolate the leak. Between
them, they started the spare parallel pump, turned off the running/­ leaking
pump, and closed its inlet, outlet, and other associated valves to isolate the leak.
Alternatively, they would have used fire hoses to suppress the leak, but this option
was rejected due to time constraints, proximity of the leak to ignition sources, and
the expanding size of the already large vapour cloud. The selection of the response
strategy appears to have been an intuitive rather than conscious ­t rade-off between
the options to isolate the leak, suppress the leak, or evacuate. The operator stated
that if the fired heater wasn’t so close, they would have been more likely to use fire
hoses to manage the leak. Using fire hoses is an inherently safer strategy to resolve
Deciphering the Knowledge Used by Frontline Workers 131

the leak as it reduces personal exposure to fumes and reduces the potential for a
fire to break out.
Even after the two operators completed the pump changeover and valve isolation,
the vapour cloud was still forming, meaning that the leak had not been effectively
isolated. The operator knew that this would be due to a pipe still being open to
the pump, meaning that they must have missed something. Therefore, the opera-
tors scanned the pipework for an open connection. Although access to the pipework
connected to the leaking pump was not an issue, it was hard to see due to the leak.
Ultimately, after less than a minute, an open pump warmup line was identified. The
line was isolated, the leak stopped immediately, and the gas cloud quickly dissipated.
The event lasted for five to ten minutes before the leak was resolved and the plane
returned to a safe state. Expressing the impact of his experience on the event, the
operator interviewed said that he was able to bring the situation to a safe conclusion
because of having seen similar and analogous events in the past. Specifically, he had
seen the same or similar events quite a few times on other pumps at the facility and
had executed a similar response two or three times.

THE ANALYSIS JOURNEY

Traditional Decision Ladder Analyses
The Decision Ladder template, which was developed by Rasmussen (­Rasmussen,
1974, 1986; Rasmussen et al., 1994) and later described in detail by Vicente (­1999),
is one of the standard Cognitive Work Analysis templates used for decision analysis.
Its flexibility and adaptability made it a logical place to start this exploratory work.
It can be used to document “­the different modes of perceptions and processing” used
by ­decision-makers (­Rasmussen, 1974, ­p. 26). The sequence is presented as “­the
steps a novice must necessarily take to carry out the s­ ub-task” (­Rasmussen, 1974,
­p. 26). Broadly, the template describes three phases of ­decision-making namely, sit-
uation analysis (­left leg), ­knowledge-based reasoning and planning (­top part), and
execution of tasks (­right leg) (­­Figure 11.1).
However, although a decision could be made by a novice operator in this order,
it has been shown by several authors that d­ ecision-making typically does not follow
this sequence. A person with experience could, for instance, have the knowledge and
experience to shortcut the novice’s approach, especially when dealing with familiar,
­low-risk tasks. These shortcuts are manifested as associative leaps between states
of knowledge (“­leaps”) or shunting between d­ ata-processing activities and states of
knowledge (“­shunts”) (­Rasmussen, 1980). In our case, the operator made observa-
tions about the condition of the plant, gas cloud, location, etc. and then made a cog-
nitive “­leap” to an understanding state of the plant and hazards. This was driven
by the operator’s years of local experience; he did not need to stop to think about it
thoroughly. Similarly, he didn’t consciously identify the steps required to swap the
pumps and isolate the leak. This is a shunt from identifying the “­chosen option” to
allocating the tasks to isolate the leak.
In general, we found that using the traditional Decision Ladder approach allowed
for a description of the patterns of operator ­decision-making. During the analysis,
132 Ergonomic Insights

F­ IGURE 11.1 A generic decision ladder template. (­

Adapted from Vicente, 1999 and
Rasmussen, 1974.)

many examples of shunts and leaps described by the refinery operators were reported
and documented, leading to a long and rich catalogue of ­decision-making shortcuts
(­i.e. shunts and leaps). However, we realised that it was difficult to explicitly docu-
ment some details of the operators’ ­decision-making. Specifically, we observed that
operators are often faced with competing goals and ambiguous or changing situations
which can result in the generation and comparison of different response options.
For instance, in this case, the operator alluded to weighing up the competing goals
of personal and plant safety and continuity of operations. The operator described
how the team implicitly, rather than explicitly, selected their response plan. In addi-
tion to intuitively generating and selecting an option, there were also responses gen-
erated and reviewed using explicit knowledge (­e.g. ­pre-established procedures, plant
drawings, and own or peer’s experiential knowledge). For this reason, we modified
the Decision Ladder template, as explained below.
Deciphering the Knowledge Used by Frontline Workers 133

Modified Decision Ladder Template

As a result of the challenges experienced when using the traditional Decision Ladder
template, we attempted a second round of Decision Ladder template analysis using a
modified version (­Lilburne & Hassall, 2019). The major difference between the tradi-
tional and modified Decision Ladder template is that it shows a more explicit descrip-
tion of option generation, comparison, and selection (­­Figure 11.2). The differences are:

• Additional states and actions have been added relating to understanding

“­gaps and ambiguity” followed by option generation, modification, and
evaluation.
• The cognitive action of “­predicting consequences” is now annotated in
three stages: “­project future states”, “­awareness of potential future state(­s)”
and “­assessing for acceptability against goals”.

­FIGURE 11.2 A modified decision ladder. (­From Lilburne & Hassall, 2019.)
134 Ergonomic Insights

• “Goal” is decoupled from the decision process where often it is linked to

“­Evaluate”.

By using this modified template across all cases, we collected, where reported
by the refinery operators, what future states they were considering and how these
states aligned with or violated their goals at different time points. It allowed
us to map out and distinguish between the different states of knowledge and
cognitive actions as described by the field operators involved, especially regard-
ing strategy selection. Thus, the modified template made it possible to catalogue
how ­decision-makers address any ambiguities or unknowns they confront during
abnormal operations. For example, in the case described above, the operators’
goals were to maintain a forward flow while resolving the leak and maintain-
ing the safety of personnel present. However, they did not report going through
a process of option generation. They intuitively “­k new” which response they
were going to attempt. In other cases, a violation of goals resulted in a conscious
weighing up of response options (­e.g. commence an emergency shutdown versus
continue operations).
The modified Decision Ladder template, however, could not explicitly and system-
atically capture how knowledge was used. For example, it did not allow for detailed
capturing of experience with past events, use of critical ­real-time data, or the input of
colleagues. All these were reported to play an important role across various aspects
of d­ ecision-making and response. Workers reported using their prior knowledge to
know how to respond, where to look for more data, or when and where to seek out
advice and expertise.
Overall, it was clear from the interview material that there was a rich volume of
data relating to the knowledge underpinning the refinery operator’s d­ ecision-making.
The challenge we faced was how to best document and understand the data. One
option was to annotate the completed Decision Ladder templates to explain the vari-
ous shunts and leaps described by the operators. While this would be a relatively
straightforward exercise for one or two cases, we thought that it was not scalable
to the whole set of cases. Additionally, descriptive annotations would not be suffi-
ciently systematic, meaning that we would risk losing consistency, explainability, and
repeatability of the analyses. Therefore, while the initial analysis rounds provided a
necessary baseline, further work was needed.

DECIMAP
A search of available HFE approaches did not reveal a tool, method, or template that
suited our purposes to identify the knowledge used by frontline workers when suc-
cessfully responding to abnormal events in different d­ ecision-making contexts and
relying on different combinations or their own or their peers’ experiential knowledge
and a range of explicit sources of information and knowledge. Therefore, we devel-
oped our own method to identify and link the different types of knowledge used dur-
ing different parts of the decision process. The tool, called DeciMap (­a shortening of
decision mapping), is more thoroughly documented in Lilburne (­2021). It is a swim
lane method where a decision process is converted to a timeline to which different
Deciphering the Knowledge Used by Frontline Workers 135

types of knowledge are mapped. Our aim was to develop a graphical, ­easy-­to-use,
reliable, and useful process.
The concept for DeciMap came about from teaching Rasmussen’s AcciMap
(­Rasmussen, 1997; Rasmussen & Svedung, 2000) to a cohort of Chemical Engineering
students. We realised that a key feature of the AcciMap aligned with our objectives
is to graphically map things (­e.g. knowledge and experience) at different levels of
abstraction to an event timeline. While DeciMap does not resemble the AcciMap, it
was the starting point that led to adopting the swim lane concept.
We then commenced working on determining how the “­lanes” should be defined
through several iterations, applications to different case studies, independent compar-
isons, and verifications. We also engaged a third person familiar with the AcciMap
process and our project to review and critique our development work. The third per-
son added much value and acted as a relatively independent challenger who ensured
that our work was more purposeful and deliberate rather than just stuff.
In the final concept, there are six swim lanes or rows (­­Figure 11.3). The upper
rows are the Knowledge rows and the lower are the Event rows. The knowledge rows
were drawn from an extensive review of knowledge, management, and human factors
literature as well as from the coding analysis of the “­Why?” and “­How?” questions
asked during the Critical Decision Method interviews (­Lilburne, 2021). The rows
capture the different sources of knowledge reportedly used by the ­decision-maker to
carry out cognitive reasoning. There are three sources of knowledge, namely explicit
knowledge and implicit knowledge gained by ­first- or secondhand experience.
The event rows document the actions of a ­decision-making, their evaluation and
judgement processes, and how the actions or knowledge of others interacted with the

­FIGURE 11.3 A blank “­DeciMap” analysis template. (­From Lilburne, 2021.)

136 Ergonomic Insights

­TABLE 11.1
Definitions Used in the Initial DeciMap Analysis
Explicit knowledge This category includes explicit knowledge used in ­decision-making,
Knowledge rows

such as observations, system ­read-outs, and drawings

Implicit, firsthand This includes knowledge gained through firsthand experiences
knowledge
Implicit, secondhand This includes secondhand knowledge gained by hearing about or
knowledge witnessing events (­e.g. “­war stories” from colleagues)
Evaluation and Describes the evaluation and judgement aspects of ­decision-making
judgement
Event rows

Actions Describes the actions of the ­decision-maker. For example, “­Making a

radio call” or “­Changing a control setpoint”
Others How people other than the ­decision-maker impacted a ­decision-
making process at the time of the event. For example, “­Advice given
by a colleague”

Source: Adapted from Lilburne (­2021).

d­ ecision-making. These rows were created based on a pragmatic way to display an event
and decision sequence and align with what can be typically captured during a Decision
Ladder template analysis. Definitions for each of the rows are shown in ­Table 11.1.
There were two outputs of the DeciMap exercise. First, we developed a catalogue
of different types of knowledge sources that can be mapped to various aspects of
­decision-making. In the case described above, these were relatively simple to docu-
ment. However, other operators described more complex interplays between their
experience, training, and specific events they had experienced. Some, for instance,
recalled ­decades-old plant failures as highly informative in their ability to respond to
analogous and different events much later in their career.
Second, it appears that the DeciMap approach may have the potential to be used
more broadly as a systematic HFE analysis tool. In this project, it was possible to
identify some patterns of how knowledge use and ­decision-making interact. It was
also possible to compare operators with different levels of experience. While the
impact of these initial analyses is hard to assess, the results were promising. Further
work now needs to be done to test, refine, validate, and assess the usefulness of the
DeciMap approach.

CONCLUDING REFLECTIONS
Our project involved two rounds of Decision Ladder template analysis of the infor-
mation collected during Critical Decision Method interviews, followed by analysis
using the DeciMap tool, which we developed, and pilot tested during this work.
Despite our extensive experience in the domain and with the decision ladder, we
found the template difficult to use to elicit the detailed insights we were seeking about
the knowledge operators used when managing abnormal situations. The Decision
Ladder template was useful but didn’t go far enough. Specifically, we struggled with
Deciphering the Knowledge Used by Frontline Workers 137

using the decision ladder to help elicit and represent implicit and explicit knowledge
used by operators. This frustration led us to develop and test the DeciMap. We were
familiar with using the AcciMap and were delighted that we found that a similar
approach could prompt and visually represent in an easily digestible form the knowl-
edge used by operators.
Overall, the initial applications of DeciMap using oil refinery operator interviews
seemed to be effective and allowed for a more thorough examination of knowledge
used in ­decision-making. We managed to gain initial insights into how operators
use different types of explicit knowledge as well as ­first- and secondhand implicit
knowledge to avert disasters. By describing different types of knowledge used by
operators using these categories, we discovered some nuances that excited us because
we believe that they could be used to improve the support given to workers to help
them manage abnormal situations. For example, we found detailed examples of how
recent abnormal events are usefully recalled alongside distant (­sometimes decades
old) abnormal events to determine response plans.
In performing this work, we learned a lot of lessons that can be related to any HFE
work so we would like to share. The first lesson we want to share is the value of hav-
ing domain expertise when interviewing workers. We certainly found value in being
able to enter a workplace and “­talk to the talk”. It allowed Chris to develop a good
rapport with the operators and draw out detailed incident accounts.
We also learned to watch out for the ­self-selection and analysis bias. ­Self-selection
bias is when individuals select themselves into a group (­e.g. interviewees for case
studies), which produces a biased sample leading to skewed and not representative
results. This form of bias is difficult to address but needs to be considered when
identifying trends or findings. The analysis bias regards the inevitable subjectivity
of the interviewer and analysts collecting and processing information. In this proj-
ect, we each performed the different analyses independently and then compared and
discussed the results to help minimise analysis bias. We found that this process also
helped us identify areas where we had differences in our interpretations.
Another lesson that stood out for us regarded the strengths that can come from
the combination of multiple HFE approaches. This was unintended at the start of
our project, but, on reflection, it was advantageous. Often, within the HFE literature,
there is some priority put on understanding which tool is the most accurate, insight-
ful, or usable in different contexts. While there is an element of competitiveness,
literature shows the different strengths and limitations of different approaches. In
our study, the combination of the original Decision Ladder template, our modified
version of the latter and the DeciMap we created was more insightful than if each had
been considered individually.
While multiple tools proved beneficial, beginning the work with a relatively sim-
ple approach was also useful. This was Chris’ first significant HFE project; when
we started the research, he was w ­ ell-experienced in the oil refining sector but had
minimal HFE experience. Chris found the Decision Ladder particularly of value as
the first HFE tool to use, as the Decision Ladder template is highly accessible, flex-
ible (­viz. forgiving), well published and documented, and quick to learn. This also
meant that it was a straightforward method to pitch to a prospective industry partner,
clear concept, mostly in plain language with existing examples of ­value-adding work.
138 Ergonomic Insights

Other more complex HFE approaches are less widely published and therefore harder
for inexperienced individuals to use effectively.
Finally, making modifications to existing HFE templates and experimenting with
creating our own approach also aided this work. Modifying the Decision Ladder
template acted as a forcing function requiring us to do a deep dive into the origins of
the template, review how others have used it in the intervening decades and give seri-
ous consideration to which version of the template should be applied for this work.
An alternative would have been to select a template with little thought, populate it,
and move on.
Similarly, developing DeciMap was a useful exercise requiring exploration of how
decisions can be documented and how different types of knowledge can be conceptu-
ally, practically, and philosophically categorised. This, again, continues a tradition of
HFE practitioners developing their own approaches, tools, and methods. It is perhaps
a big leap for a novice HFE practitioner to begin developing their own tools and
methods. However, on reflection, there are plenty of published methods, tools, tem-
plates, and variations thereof, each designed and tested for its own bespoke purpose.
For this work, we could find no existing tool that would meet our analysis goals. An
alternative to DeciMap would have been to simply extract and code different knowl-
edge types into a spreadsheet or other tool, leading to a much less rich outcome.
Clearly, if DeciMap and the Decision Ladder template modifications are to have an
impact beyond this work, more testing and application are needed. However, from
an analysis and HFE practitioner perspective, we believe that the time invested in
understanding, developing, and documenting operational knowledge was extremely
worthwhile. We hope that by publishing our work here, others will try it to produce
interesting findings and the nuances in knowledge use that underpins both successful
and unsuccessful attempts to manage safety critical abnormal situations in the indus-
try. And we also hope that these findings will lead to work system design innova-
tions that better support workers to produce successful outcomes, thereby preventing
fatalities and catastrophes.

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 12 The Tyranny of Misusing
Documented Rules
and Procedures
Nektarios Karanikas
Queensland University of Technology

CONTENTS
Rules and Procedures as Parts of Work Design...................................................... 142
Same Procedure, Different Actors.......................................................................... 144
With the Book or By the Book?.............................................................................. 146
A Few Last Thoughts.............................................................................................. 150
References............................................................................................................... 151

As with my contribution to the previous book in the same series, which was about
safety insights (­Karanikas, 2020), the context of my cases is the highly demanding
operational environment of a military aircraft squadron. While writing these lines,
I realised that the two years when I was a chief engineer with an enormous pile of
responsibilities for staff and equipment left valuable marks on me. Although before
and after this role I had several important duties at operational, tactical, and strate-
gic levels, I believe my successes and failures during my duties as a chief engineer
were more impactful on my growth as a professional. This relates to the position of
this role in the organisational structure. On the one hand, you are responsible for the
health, safety, ­well-being, and professional currency of the staff trusted in you and
for the availability and airworthiness of the aircraft and other ground equipment in
the squadron. On the other hand, you are accountable to the squadron commander,
and, by extension, the operational base commander, and the rest of the management
levels. Simply put, you cannot hide from anyone. What I was doing was visible in all
directions, upstream and downstream.
As with most organisations, especially large ones, rules and procedures were
inextricable parts of our work design. We could find them everywhere, and they
drove the “­who, where, when, what and how” of our activities. Compliance with
those documents was expected from everyone and was ingrained in us since the early
days of our military and engineering education and training. Rules and procedures
were the reference points to service aircraft, schedule and perform maintenance,
license technicians, keep records, submit reports, etc. Any deviation from those,
especially the ones that dictated our safe interactions with aircraft (­e.g. refuelling or
inspections) could incur implications for staff, supervisors, and managers, including

DOI: 10.1201/9781003349976-12 141

142 Ergonomic Insights

myself, regardless of whether the outcome of a procedural deviation was an incident/­

accident or not. Of course, when the result was adverse (­e.g. injuries or damages), the
personal consequences across any organisational level involved were worse.
I was supposed to monitor everything and ensure compliance. You could wonder
how this was possible with tens of staff at different places performing various activi-
ties within diverse environments and varying operational demands. I was wonder-
ing too but worries alone can change nothing. I had to do my job and help everyone
keep safe, productive and happy. However, sometimes someone needs to be a sort
of rebel and challenge established rules and procedures when these do not serve the
needs of the staff and the work. The cases that I am sharing focus exactly on two
of my attempts to change the status quo. However, before moving to the stories, the
next section includes my understanding and reviews some literature about rules and
procedures. I believe this can help you interpret my decisions and actions described
later in the cases I share.

RULES AND PROCEDURES AS PARTS OF WORK DESIGN

I presume when someone mentions procedures, our minds often bring up pictures of
short or long documents prescribing what we are supposed to do in specific circum-
stances, how to use our new gadget, how to enter and analyse data in a software pack-
age, how to maintain a machine, how to drive our car, etc. When referring to rules,
our brains typically recall the written and unwritten “­laws” of what others expect
us to do and achieve or not. We should not interrupt others when speaking, we are
expected to help others in need, we should report an accident to the authorities or a
medical condition to our insurer, etc. Simply put, rules usually represent the “­what”
and procedures complement rules by describing the “­who, where, when, and how” of
matters. The only interrogative question missing from the list above is the “­why”. I
will come back to this important aspect later in the chapter.
Nonetheless, from a more abstract level, procedures as stepped approaches to com-
plete activities within a set of rules (­i.e. boundaries of what we can do) are present in
the very early years of our lives. They are not written, but this does not render them
inexistent. Our brains observe, process, sometimes imitate what others do and achieve
and, with the coordination of our body parts, use procedural steps to carry out daily
activities to yield the intended outcomes as dictated by internalised rules. Our internal
software continuously grows, changes, and adapts to what we sense, and it continually
develops new and modified “­if, then, else” loops to complete several missions under-
pinned by these various stored rules, which also can change with time.
However, in the work context, even if we are given rules and we memorise these,
we do not always have the luxury to become shadows of more experienced profession-
als and learn through practice how they do the job successfully, presumably accord-
ing to the rules. Some tasks that we could be asked to perform in the future might
not be possible for others to demonstrate if an operational need does not arise. Even
when such a demonstration becomes possible physically (­e.g. o­ n-­the-job training on
mock equipment) or virtually for a limited time (­e.g. in simulated environments or
video recordings), nobody can claim that we really master tasks after a couple of suc-
cessful attempts following demonstration and performance under supervision.
Misusing Documented Rules and Procedures 143

Furthermore, experienced staff might not be the perfect examples of how work
should be expectedly done according to procedures and rules. Long and rich work
experience increases our confidence, overconfidence might lead to overestimating our
capabilities, and this, in turn, leads to drifts from procedures without prior consider-
ation of what could go unintentionally wrong. Indeed, someone with substantial work
experience might deal successfully with the unexpected results of procedural devia-
tions, but an inexperienced employee might just freeze, run away, lose control of the
situation, etc., with dire consequences. That was one of my major concerns in my role
as a chief engineer several years ago. I was worried when novice technicians were just
imitating experienced workers who did not follow procedures exactly, but the former
individuals did not yet have developed capabilities to confront unfamiliar situations.
Add to the above the fact that experienced workers with valuable knowledge might
leave an organisation and our brains can forget procedural steps and rules, especially
when we do not practise them often. We might also omit steps, usually when we
do something very often. All these are the main reasons for documented rules and
procedures. As Pasquini and Pozzi (­2005) explain, different procedures aim mainly
to facilitate the integration between operators and equipment, including, of course,
the cooperation among operators. However, the critical aspect when designing proce-
dures is that we must view the ­human-­tool-procedure system as a whole within their
physical and social work environment (­Pasquini & Pozzi, 2005).
For instance, whereas Bleyl and Heller (­2008) observed that Standard Operating
Procedures in healthcare can increase workload but support h­ igh-quality patient care,
in the same industry sector, Thomas and Spain (­2012) warned that safety is more
than policies, processes, and procedures. Amongst other work stressors, the authors
above referred to the nature of the work performed, comprehensibility and accessibil-
ity of procedures, management styles, supervisory capacity, teamwork, and collegial
relationships. Referring to rules, Hale and Borys (­2013b) identified two approaches
in the literature, namely (­1) ­top-down enforcement of rules as static, comprehensive
limits of freedom of choice and (­2) ­bottom-up constructivism where rules are dynami-
cally, locally, and situationally constructed through competence and ability to adapt
them to different work realities. As a reconciliation of those two approaches, Hale
and Borys (­2013a) suggested a framework of rule management that acknowledges the
necessity of monitoring and adapting rules through worker participation and regular
and explicit conversations between users, supervisors, and technical, safety, and legal
experts. The combinations of t­ op-down and ­bottom-up paths when creating objectives
and procedures were also claimed as indications of the balance between systematic
management and systems thinking in an organisation whereby performance variabil-
ity is controlled and accepted to different extents (­Karanikas et al., 2020).
Indeed, in the mining maintenance context, Kanse et al. (­2018) identified that pro-
cedure management strategies played a more positive role when providing learning
opportunities than punishment for deviations, and users were more keen on complying
when engaged in procedures’ design and review. Bringing the above to the aviation
context, where both my success and failure cases refer, Carim et al. (­2016) proposed
that procedures should not be viewed as controlling constraints but resources to sup-
port actions because situations encountered by pilots can be far more complicated
than what procedures are designed for. Therefore, amongst other strategies for the
144 Ergonomic Insights

design of procedures, these should provide pilots with choices rather than mandatory
steps. As Provan and Rae (­2020) concluded, although we need rules and procedures
within organisations to enable work to be performed safely, the challenges of the
dynamically changing work environment warrant a critical review of the applicabil-
ity of rules and procedures within an organisation.

SAME PROCEDURE, DIFFERENT ACTORS

One of the critical preflight phases is what we call the “­­last-chance” check. In our
organisation, we performed this just before the aircraft entered the runway to line
up for ­take-off. This check includes a visual inspection of several critical systems to
detect any issues that could threaten flight safety (­e.g. impacts on tyres after taxiing
towards the runway, leakage from hydraulic and oil pumps and accumulators, or
loose screws on surface panels). If the technician finds a problem, depending on its
magnitude, he/­she might call for a more experienced technician to check again or
can immediately instruct the pilot to cancel the operation and return to the squadron.
The “­­last-chance” tasks are performed based on a prescribed procedure (­i.e. what
and how to inspect and in what order) in a very noisy environment because of the
aircraft engines running. Also, the technician must move below the aircraft surfaces,
meaning that there is no eye contact with the pilot for some of the activities’ duration.
To avoid any unintentional harm to staff by moving surfaces (­e.g. wing flaps), the
pilot lifts his/­her arms high and away from any lever, switch, etc. when the techni-
cian asks for it. The pilot moves the aircraft surfaces only when in eye contact with
the technician upon the instructions of the latter. Those surface movements allow the
technician to detect any anomalies (­e.g. fluid leakages or inconsistent surface move-
ments). When the task is finished without findings, the technician signals to the pilot,
he/­she steps away from the aircraft, and the mission continues.
In this process, there are two additional risk control measures in place. First, as
in most cases of servicing and maintenance tasks with the engines running, there
is a fire extinguisher close to the inspection area. In case of a fire in the engine or
other aircraft systems (­e.g. leakage of hydraulic on the very hot braking system), the
technician can prevent or mitigate the expansion of the fire by using the extinguisher
while also communicating with the pilot through standardised visual signals. The
second control measure is an extra technician who keeps a safe distance from the
aircraft under inspection but continuously maintains eye contact with the pilots. This
ensures that if something goes wrong with the technician inspecting the aircraft
(­e.g. medical condition) when not visible by the pilot, the supervising technician will
inform the flight crew and instruct them further (­e.g. shut down the engines).
Notably, the “­­last-chance” supervisor usually monitors two inspections at the same
time by keeping a distance that allows an adequate view angle to cover both aircraft,
which are usually stopped next to each other with a safe distance between them. If
there were more aircraft to be inspected, they either had to wait for the inspections
of the first pair of aircraft to finish or we had an extra team available to conduct
the “­­last-chance” tasks. Moreover, although the inspections could be carried out by
any fully licenced mechanical technician, the procedures foresaw that we should
appoint only an experienced or inspector mechanical technician to the supervisory
Misusing Documented Rules and Procedures 145

role. The classification for all technicians across the organisation was Level 3 for
fully licenced, Level 5 for experienced technicians, and Level 7 for inspectors.
All the above were great, and everyone complied to ensure the safety of everyone
and everything. However, just after a few weeks in my role, I noticed that sometimes,
especially during night operations, there was much urgency and tension when it was
time for the “­last chance”. Sometimes I was hearing this on my portable radio device
and other times I was witnessing it with my own eyes; teams of technicians running
around frantically to get into the vehicle that would drive them to the “­­last-chance”
area. Anything that has to do with anxiety and speed in s­ afety–critical environments,
and at work in general, is concerning to me. I had to understand what was going on.
It took me only one discussion with the staff to realise the reasons for the situation
above. Simply put, there was low system capacity because of staff shortages. There
were only a few Level 5 and 7 mechanical technicians per shift, about ­3 –4 during
day operations and only ­1–2 in the night shifts. These specialists had to attend sev-
eral works at the flight line and the maintenance hangar to ensure that enough air-
craft were available on time. When it was time for the “­last chance”, it could happen
that some of these specialists were occupied with critical duties that did not afford
them the luxury to stop and restart their jobs or they were away from the squadron for
other tasks (­e.g. transferring components to and from the depot). Thus, although the
maintenance scheduling office was trying its best to have experienced technicians
available during flight operations, there was usually only one Level 5 or 7 mechani-
cal technician who could undertake the supervisory role by rushing from one task to
this one, together with the rest of the technical team.
I first investigated whether I could increase Level 5 and 7 staff capacity day and
night. Unfortunately, this was not possible for several reasons (­e.g. lack of experi-
enced Level 3 technicians to be elevated to Level 5, absences because of personal
leave or needs for operations at remote locations, necessary resting period between
shifts). Then, I looked at the work itself. I started by consulting with the documents,
including the organisational directive that established the “­­last-chance” procedure
a few years later. The intent was commendable as it ensured operational safety; no
technician denied the need to have this procedure. However, I realised that, while
issuing the procedure, nobody had considered the resource implications and the par-
ticularities of each squadron. It was a document that applied everywhere uniformly,
regardless of the context. Whereas in several cases the “­­last-chance” area was next
to the squadron, in our case, the teams had to drive about 5 km to reach that area. It
could not be different because of the design of the runway in our base and the need to
perform these inspections just before the aircraft were about to line up for t­ake-off.
Hence, I could not change this part of the work system.
Afterwards, I witnessed twice the task conducted in real time. The technicians
complied with the procedure, and no step seemed to me unnecessary. However, the
second time I observed the task, I had my eureka moment! Yes, I concurred that a
Level 5 or 7 technician must have the supervising role, but why a mechanical tech-
nician only? I did not notice any supervisory task which needed mechanical exper-
tise! Monitoring the area for abnormalities, helping with extinguishing the fire if
any existed, and signalling the pilot were tasks that all experienced technicians were
licensed and able to do regardless of specialty.
146 Ergonomic Insights

The next day, I invited all Level 5 and 7 technicians to my office, including mechan-
ical, electrical, and avionics and ­fly-­by-wire specialists. I shared with them my observa-
tions and thoughts above. The mechanical specialists were happy but sceptical about
whether the rule could change. The rest were unhappy because they would be required
to do more. The efficiency driver of human survival struck! Nonetheless, I explained
to them that the workload would not be significantly higher because it would be shared
amongst all Level 5 and 7 personnel, and the task mostly necessitated monitoring from
a safe distance. I also explained the benefits for their mechanical expert colleagues and
everyone in the squadron. Nobody amongst us would like to hear about or experience
an injury because of the rush to squiz people and tasks and drive fast to and from the
“­­last-chance” area. It did not take long. Collegiality and solidarity prevailed.
The next thing to do was to receive approval for this change from management.
I discussed our idea with the squadron commander, and he agreed I would submit a
formal request to the base management. I did so by describing the particularities of
our squadron (­i.e. far from the “­­last-chance” area), the staff capacity limitations, the
gains from this recommended change to allow any specialty for the supervisor role,
the absence of any additional risks, and, most importantly, that no extra training or
other resources were necessary. We just needed a formal change of the rule so that
we could amend our local procedures.
However, having experienced severe response delays in the past or hesitancy to
change rules, this time I added something extra to my request. Instead of just ask-
ing for approving the change, I informed the base management that we would start
implementing the revised procedure in two weeks if we had not received an answer
prohibiting the change. For the military context, that was rebellious! You are only
supposed to request and wait, possibly nudge in the meantime. Until you receive a
formal response, you must follow the ­top-down imposed rules and procedures. Of
course, it did not take long before I received a phone call from the base’s maintenance
director. He shouted, “­Who do you think you are? How dare you arbitrarily change
procedures decided at senior organisational levels?” With all due respect, I asked
back “­Do you deny that we have a problem to solve? Did you find anything in the
recommended change that is not workable or inflicts additional risks? Does the base
have any alternative way to help me solve this issue?” He hung up.
Indeed, the base never formally replied to my request, positively or negatively.
Back then, they informed me orally that they were seeking approval from the tacti-
cal level because the directive had been issued by them and affected several bases
and their nested squadrons. Unsurprising development, I said to myself, for a large,
highly structured, and bureaucratic organisation. Nonetheless, in the squadron, we
proceeded as planned. We changed our internal procedure and since then everything
was running more smoothly and with less stress. The mission of work redesign to
match the local context was accomplished. If I am not wrong, the t­actical-level rule
has not changed since then.

WITH THE BOOK OR BY THE BOOK?

In the defence sector, the mantra “­prepare for war during peace times” drives every-
thing. Indeed, this is what this sector does when not in warfare. One of the critical
Misusing Documented Rules and Procedures 147

activities is to run drills that simulate war conditions to evaluate the system’s per-
formance and improve. In our organisation, such drills were taking place a few
times throughout the year at all operational bases. They were announced by the level
responsible for evaluating our readiness. These would be the operational, tactical, or
strategic levels. I cannot even count how many times I was involved in those drills. I
admit that they were great experiences. Everyone was alert and prepared to contrib-
ute to defending against the virtual enemy! They were also valuable opportunities
to discover any shortcomings and perform better next time at individual, team and
organisational levels. After each drill, a report from the inspecting authority shared
the findings, both positive and negative. The latter ones concerned, operational bases
and squadrons should come up with actions to rectify any issues. We were supposed
to recommend how to change our work systems and/­or design!
Notably, those drills were not focussing only on whether we could deliver the
right service/­product on time, but also on whether we could deliver it safely and sus-
tainably. No defence organisation wants to suffer from lower warfare capacity and
capabilities due to staff injured and aircraft damage because of internal issues. We
needed staff and equipment available for and being capable of continuous operations
to secure a win without harming citizens and destroying the natural environment!
Therefore, the assessors were looking at several aspects beyond the success of air-
craft operational missions, including physical and cyber security, health and safety,
training and licencing, maintenance capabilities, impacts on communities and the
environment, etc. Documented rules, procedures, and checklists about where and
what to check were inextricable parts of these evaluations.
During one of these drills organised by the tactical level, I was sitting together
with an assessor to discuss several aspects. Those discussions were important for the
assessors to gain a better understanding of the context and ask questions about their
findings (­e.g. remedies we already planned for but were possibly delayed). Also, these
conversations were opportunities for us to share with other organisational levels our
struggles and ideas. One technician came close and apologised for interrupting us.
He seemed nervous. The technician reported that one assessor rebuked a team per-
forming a “­turnaround” because most of them were not holding their checklists.
Moreover, the assessor informed them that he would report this as an important
finding. During the drills, as we knew we are evaluated, we felt much pressure. We
should perform perfectly!
The “­turnaround” process includes aircraft inspection, servicing with fuel and oil,
and reloading with weapons in a very limited time, assuming that the aircraft just
returned from a battle and should be ready the soonest possible for the next mission.
The same process happens during training missions but in a different setting. The
“­peacetime procedure” expects that a Level 3/­5 mechanical technician will inspect
the aircraft, replenish oils and hydraulics if necessary, and refuel it with the support
of another licenced staff member. Then, the armament team (­­2–3 technicians of all
levels) will load the aircraft with the weapons required, and a Level 7 mechanical
technician will perform the last inspection.
Notably, there are specific works not permitted on the aircraft when load-
ing weapons or refuelling. This is to avoid catastrophic consequences, such as the
unintentional activation of weapons (­e.g. someone touches the wrong switch). Next,
148 Ergonomic Insights

everyone signs off the maintenance forms, and the aircraft is reported available for
its training mission. Of course, if the mechanical or armament technicians notice any
problem, further actions are taken. After all these steps, the pilot checks the forms
and inspects the aircraft together with a technician, and, if everything looks good,
the rest of the mission continues. The servicing part by the mechanics took about
­40–45 minutes, and the duration of the armament depended on the weapons needed.
The latter could add 30 minutes for the “­simplest” configuration to several hours for
the “­heavy” configuration. For a simple configuration, add the time for signing off
forms and the rest of the steps outlined above, and we get about 90 minutes for the
entire process.
The difference in wartimes (­and drills!) is that the ­90-minute process must be
completed in less than 30 minutes with all technicians working simultaneously to
prepare the aircraft for its mission. To achieve this on time and safely, the mechanic
team is usually supported by another technician, and the Level 7 mechanic under-
takes the role of the “­turnaround” supervisor. Since different tasks are carried out in
parallel, the procedure has been designed in a way that avoids overlaps and bottle-
necks (­e.g. staff performing a different job in the same area) and ensures that safety
risks are controlled (­e.g. no electrical checks when weapons are loaded or during
refuelling). Therefore, imagine a team of six persons plus the refueller amidst sev-
eral equipment, tools, and weapons working hard to complete their ­operation- and
­safety–critical jobs in a very limited time with a restricted area defined by the limited
dimensions of the military aircraft. The adrenaline gets to the top levels!
Well, the good news is that we were all gradually trained for this before any
drills. Nobody was suddenly asked to perform this highly demanding job without
prior experience. As part of this training, we were consulting with the “­turnaround”
checklist to understand the differences from the regular process and we were accom-
panied by experienced persons to perform the tasks in the specific order by holding
our checklists, then gradually working with other technicians to complete the pro-
cess, and, finally, performing the “­turnaround” faster and faster until we lowered its
duration to the desired length. We were not rushing things further as we were aware
that this would increase health, safety, and operational risks because the process was
already designed with almost no slacks and no room for deviations.
Nonetheless, as we were gaining more experience in our tasks during the
“­turnaround” training, we left aside the checklists because they became obstacles
rather than supportive items. Imagine running around to complete your job the
soonest possible with safety and quality while your one hand is occupied by the
documented checklist. Impossible! However, the supervising technician was always
holding the checklist as a reminder of the order and type of tasks to be carried out by
the different team members at each time point. When the supervisor noticed some-
thing abnormal, she/­he provided appropriate instructions or reminders (­e.g. next task
to be completed). After the process was finished, the supervisors gave us feedback
and explained to us any slips and lapses by referring to the checklist. Each time, we
studied the checklist again, and we did it better the next time. Therefore, whereas we
required inexperienced trainees to hold the checklist (“­with the book”), we expected
experienced staff to work “­by the book” while the supervisor monitored everyone
while holding the checklist and consulting with it.
Misusing Documented Rules and Procedures 149

Unfortunately, that was not the perspective of the assessor who criticised the tech-
nicians in the specific case. I invited the assessor and his team leader to discuss this.
The assessor repeated that he noticed exactly what I described above; the technicians
performed the “­turnaround” while only the supervisor held the checklist. This meant
that, from my point of view, there was no gap between what we had planned and what
the team was doing, or between Work As Imagined and Work as Done as Hollnagel
(­2014) defines it. To verify this further, I asked the assessor whether he observed
any safety and quality issues with the process and whether all steps were completed
in the right order and on time. He admitted that the “­turnaround” he attended was
exemplary. Great news!
Then I asked him why he persisted on this issue of all technicians holding the
“­turnaround” checklist. He replied that his own inspection checklist required so.
I kindly asked to read his checklist, which mentioned that the process should be
carried out according to the approved “­turnaround” checklist. Nowhere did I read
that the technical team should hold their checklists while doing their job. Obviously,
it was a matter of different interpretations. The assessor insisted that his checklist
required a “­­with-­the-book” process, and I was advocating that the checklist meant
“­­by-­the-book” performance of the tasks. When it came to arguments to defend our
positions, the assessor had nothing else to use apart from his understanding of the
checklist and the fact that he had applied the same concept during other drills, and
everyone complied. Well, this last thing was concerning to me.
I explained to him that the risks of holding a book during the “­turnaround”
process with the expectation to consult with it (­otherwise, there would be no need
to hold it) was dangerous. The staff focussed on completing their critical tasks in
a limited time while not inflicting delays, harming others, or damaging the air-
craft and their equipment. Had they had to read their checklist before each step, or
sets of steps, it would be highly distracting. Not only would this delay the whole
process, but it would also divert the cognitive capacity of technicians to an unnec-
essary activity. We were indeed prepared very well for the ­d rill – warlike environ-
ment by consulting the ­checklist – and now it was time to demonstrate what we
can do! Can you imagine someone holding the driving manual of his/­her car or the
book with the road signs and reading it while on the road? The assessor’s interpre-
tation of his inspection checklist made no sense to me. He provided no convincing
answer to my “­why?”
The lead assessor was more political. He admitted that he agreed with my inter-
pretation and our practice, but he could not enforce his opinion on the other assessor
who, on the one hand, also shared my concerns, but, on the other hand, stuck with
his decision to report his observation as a finding. Every additional attempt from
my side to deter him went wasted. It was not only about our squadron or whether
we would be “­charged” with a noncompliance finding. It would not be the first time.
I was more worried that he would impose his interpretation of using checklists
on other bases and squadrons. Within military structures, rarely would someone
challenge the opinion of senior management levels. In this case, armed with my
knowledge of human factors and safety, I dared to present substantive arguments,
and I openly refused to comply. Would others do the same? Would they resist this
insensible perspective?
150 Ergonomic Insights

After a few weeks, we received the report, and the alleged finding was there as
expected. The squadron commander asked me about it. I described to him all the
above. He was silent for a minute or so. Then, he said, “­I trust you will do the best
for our staff”. I replied, “­I will not comply”. We decided to report back to senior
management on this finding by stating “­continuous efforts to comply”. That was a
typical ­close-off statement throughout the whole organisation for items we did not
have something tangible to suggest or a good excuse. We never put in any extra effort
to comply with the “­­with-­the-book” requirement during “­turnarounds”, at least while
I was the chief engineer in the squadron. We continued to do our best to deliver effec-
tive ­on-­the-job training and minimise health, safety, and operational risks.
Could I have done something differently? Back then, I felt any official letter dedi-
cated to this misinterpretation of how checklists are supposed to be used would get
lost in the bureaucratic maze of our large organisation. In hindsight, I could have at
least tried. I regret it now. I could have also invited the assessor to a drill performed
in his way, meaning “­with the book” and not just “­by the book”. However, I did not
want to impose this unnecessary experimental risk on staff to reinvent science for the
sake of someone’s denial to accept it. The best I could do, and I did, was to continue
to be close to the technicians, consult with them, share with them my knowledge,
experience, and advice, and work out together the best ways to minimise risks.

A FEW LAST THOUGHTS

Whether written rules and procedures can be friends or enemies depends on every-
one’s contribution. Authors, auditors, operational managers, and users must all work
in tandem and genuinely design and redesign documented ways of work. This of
course lies more on the initiatives of senior leadership and management to create
bridges with others and create a psychologically safe environment where everyone
can respectfully discuss and debate. I believe that, in this way, even the term “­Work
as Imagined” would be obsolete because it implies that others decide about our work
on our behalf and without us.
Instead, a collaborative and open environment would lead to create Work as
Agreed, which should be continually revised based on s­ hop-floor experiences of Work
as Possible. This would establish the “­why” of matters to supplement the “­what” of
rules and the “­who, where, when, and how” of procedures. Work as Imagined can be
as dangerous as Work as Done when the former does not match the work context and
when locally emerging practices are not informed by collective discussions about
and assessments of side and unintentional risks.
Furthermore, I argue that not all agreed works have to be documented to be
enacted. The work environment is a living environment, and as life cannot be put on
a paper, the same applies to work systems. Indeed, a legitimate question would be
“­How much should we document?” You can call me theoretical and idealist, but I do
not think that one size fits all when it comes to the length and number of procedures.
Inexperienced workers might need detailed information about both rules and proce-
dures. Experienced workers who have internalised rules and procedures might need
summaries or more abstract representations of rules and procedures, while also hav-
ing the opportunity to get back to the detailed ones. Here, certainly, the importance
Misusing Documented Rules and Procedures 151

of awareness and collegial culture play a hugely important role. We must be able to
alert each other to get back to the detailed procedures when our practices threaten
the integrity of the system and continually ­risk-assess together and feedback to the
system on any necessary deviations.
Therefore, assuming a mature organisational culture, my response to you would
be “­as much as it gives each worker cohort the opportunity to access the informa-
tion needed to perform the job as expected”. If you decide to have lengthy pre-
scription documents for everyone, I understand. We do not have the resources to
tailor everything to everyone. Also, maybe you do not trust the workers and vice
versa to establish a ­Work-­as-Agreed and ­Work-­as-Possible environment. Trust is
another crucial organisational parameter, but its discussion can be long, and it is
outside the scope of this chapter. Nonetheless, in this case of a highly prescribed
work environment, we could also describe what we expect from each cohort when
it comes to compliance. Do we want tasks to be performed by the book or with
the book and when and by whom? Do we think that holding the book will make
people safer? Do we expect people to apply our procedures religiously or adapt
them to their context based on the approach recommended above? What are we
prepared to do if such adaptations usually succeed but sometimes fail? I urge us
all to think again.

REFERENCES
Bleyl, J. U., & Heller, A. R. (­2008). Standard operating procedures und OP-Management
zur Steigerung der Patientensicherheit und der Effizienz von Prozessabläufen.
Wiener Medizinische Wochenschrift, 158(­21), 595–602. https://­doi.
org/­10.1007/­s10354-008-0607-y
Carim, G. C., Saurin, T. A., Havinga, J., Rae, A., Dekker, S. W. A., & Henriqson, É. (­2016).
Using a procedure doesn’t mean following it: A cognitive systems approach to how
a cockpit manages emergencies. Safety Science, 89, 147–157. https://­doi.org/­10.1016/­j.
ssci.2016.06.008
Hale, A., & Borys, D. (­2013a). Working to rule or working safely? Part 2: The management
of safety rules and procedures. Safety Science, 55, 222–231. https://­doi.org/­10.1016/­j.
ssci.2012.05.013
Hale, A., & Borys, D. (­2013b). Working to rule, or working safely? Part 1: A state of the art
review. Safety Science, 55, 207–221. https://­doi.org/­10.1016/­j.ssci.2012.05.011
Hollnagel, E. (­2014). Safety-I and Safety-II: The Past and Future of Safety Management.
Ashgate.
Kanse, L., Parkes, K., Hodkiewicz, M., Hu, X., & Griffin, M. (­2018). Are you sure you want
me to follow this? A study of procedure management, user perceptions and compliance
behaviour. Safety Science, 101, 19–32. https://­doi.org/­10.1016/­j.ssci.2017.08.003
Karanikas, N. (­2020). Necessary Incompliance and Safety-threatening Collegiality. In N.
Karanikas & M. M. Chatzimichailidou (­Eds.), Safety Insights: Success & Failure Stories
of Practitioners (­p­­p. 139–148). Routledge. https://­doi.org/­10.4324/­9781003010777-13
Karanikas, N., Popovich, A., Steele, S., Horswill, N., Laddrak, V., & Roberts, T. (­2020).
Symbiotic types of systems thinking with systematic management in occupational
health & safety. Safety Science, 128. https://­doi.org/­10.1016/­j.ssci.2020.104752
Pasquini, A., & Pozzi, S. (­2005). Evaluation of air traffic management procedures—safety
assessment in an experimental environment. Reliability Engineering & System Safety,
89(­1), 105–117. https://­doi.org/­10.1016/­j.ress.2004.08.009
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Provan, D., & Rae, A. (­2020). Rules and Procedures. In The Core Body of Knowledge for
Generalist OHS Professionals (­2nd ed.). Australian Institute of Health & Safety. https://­
www.ohsbok.org.au/­wp-content/­uploads/­2020/­04/­12.3.1-Rules-and-procedures.pdf
Thomas, S., & Spain, J. (­2012). A Manager’s Perspective: Patient safety/­employee safety:
Much more than policies, processes and procedures. It’s a culture! Canadian Journal of
Medical Laboratory Science, 74(­1), 16–18.
 13 Creating Ownership and
Dealing with Design and
Work System Flaws
Stasinos Karampatsos
Hellenic Air Force

CONTENTS
Task Ownership in Process Improvement............................................................... 154
Undetected Design and Work System Flaws.......................................................... 157
Concluding Remarks............................................................................................... 160
References............................................................................................................... 160

The context of both cases below is the everyday operations of an aviation organisa-
tion with ­state-­of-­the-art, ­high-performance ­fixed-wing and rotorcrafts, piloted or
unmanned. The organisation operates its aircraft daily and with a high frequency,
and it can conduct operations anywhere in the world with proper maintenance capa-
bility and support for operations. Considering the high procurement costs of planes
and the dire consequences of an ­in-flight failure (­e.g., human injuries or losses,
equipment damage, or a crash into populated areas), the requirements for preven-
tive aircraft maintenance and repairs are treated with attention to detail and extreme
seriousness (­EU, 2018). Work of this kind comprises most tasks of an aircraft mainte-
nance organisation, supported by the logistics chain. Of course, apart from safety, the
availability of serviceable aircraft is paramount for the missions of business units.
This specific organisation has a quality management structure that conforms
to international standards and is based on the general principles and guidelines of
Deming’s ­Plan-­Do-­Study-Act philosophy (­Evans & Lindsay, 2008).1 There is dedi-
cated support for logistics and airworthiness and engineering departments in accor-
dance with internationally accepted directives (­EU, 2014; EDA, 2021). Each o­ n-site
maintenance unit includes ­flight-line services (­i.e., operational/­­basic-level mainte-
nance) and base maintenance (­i.e., ­intermediate-/­­second-level maintenance) but no
depot maintenance capabilities (­USDS, 2021). Organisational elements that deal
with quality assurance and health and safety issues are also included in this structure.
The following cases are from my observation as a maintenance unit manager, having
undergone approved training as an aircraft engineer, being a subject matter expert in

1 https://­deming.org/­explore/­pdsa/

DOI: 10.1201/9781003349976-13 153

154 Ergonomic Insights

quality and risk management, being a certified project manager, and having extensive
experience in managing medium to large teams.

TASK OWNERSHIP IN PROCESS IMPROVEMENT

System faults can obviously hinder the safe use of equipment and/­or the execution
of organisational missions. Hence, a good deal of maintenance organisation’s efforts
goes towards remedying such faults. However, repairs are usually the smaller part of
the work than the volume and duration of the tasks of preventive maintenance, where
standard practices for the design and use of aircraft apply. Preventive maintenance
aims to counter two major deterioration categories. One of those is wear and tear
due to the operation of aircraft. For example, the accumulation of a specific amount
of flight hours requires the replacement of certain components that are subject to
stress during flights. If not replaced, those parts could fail due to cracks or other
­fatigue-related issues. The second category regards wear due to environmental fac-
tors and the interaction of aircraft systems with their surroundings (­e.g., oxygen or
ultraviolet radiation). Such maintenance takes place at regular time intervals, usually
regardless of the operation frequency of aircraft.
Aircraft manufacturers primarily utilise steel, aluminium, and other nonferrous
alloys to achieve reduced weight and higher performance (­FAA, 2018). However, in
the environments that the aircraft operate, these structural materials are prone to
corrosion, especially in combination with high mechanical stress during flight opera-
tions. Consequently, dealing with corrosion issues is a primary concern for aviation
organisations and a major part of preventive maintenance activities. In this case,
corrosion issues arose in critical structural elements of the aircraft. Failure/­damage
critical components are the ones that support loads and if damaged or degraded in
strength can lead to structural failures. These failures could result in serious or fatal
injuries, or extended periods of operation with reduced safety margins (­FAA, 2021).
The corrosion prevention schedule is the process through which aviation organisa-
tions deal with such problems.
In this case, the type and extent of the corrosion damage found far exceeded
the allowable limits. Thus, it was necessary to alter the corrosion prevention sched-
ule of aircraft, apply corrective measures, and carry out all these as soon as pos-
sible to avoid potential ­in-flight mishaps. The business unit dealing with ­basic-level
aircraft maintenance had the responsibility for dealing with the transition from the
“­business as usual” state to a totally new one, within a relatively short timeframe;
initial steps had to be taken within a week, and a complete overhaul of the schedule
should be completed in under a month. This would involve a drastically differenti-
ated maintenance schedule and increased maintenance requirements. However, the
strict timeframe did not allow for implementing broad ­organisational-level changes
(­e.g., completely new roles and responsibilities for each maintenance level) or allocat-
ing considerably more resources (­e.g., committing additional technicians, time, and
equipment already necessary for other activities).
Thus, the ­top-­down-imposed ­goal – I had in my role as the maintenance unit
­manager – was clear: incorporate the new maintenance requirements in the ongoing
work without affecting operations, as soon as possible. Dealing with such a situation
Dealing with Design and Work System Flaws 155

falls within the definition of a project, where project and change management prin-
ciples apply (­PMI, 2021). Having a clear scope and schedule, I set forth to create an
action plan for the necessary changes. The plan was to unfold in two different direc-
tions. One was to foster ownership of the changes throughout all organisational lev-
els, both upstream and downstream; the importance of such ownership will become
clear below. The other was to incorporate these changes into the already existing
organisational processes through process improvements and avoid any sudden shift
in the operational focus. The main mission of the business unit was primarily to
support flight operations, and the resources available were allocated in such a way
as to prioritise that. Therefore, the plan required all stakeholders, from ­front-line
workers to senior management, to be informed and involved accordingly. Also, for
the plan to succeed, the changes required had to be clearly defined. These changes
could be organisational, ­task-related, procedural, or related to roles and responsibili-
ties throughout the organisation or only the business unit. It was the burden of the
business unit and mine to design these in accordance with the new maintenance
requirements, implement those within my purview, and propose and support their
acceptance with the minimum possible resistance from the organisation.
The new maintenance schedule was to be implemented as soon as possible. While
the plan was initially put in motion in the business unit, the corrosion prevention
tasks were assigned to the base maintenance level. The reason was that its staff was
more competent and could perform the necessary work faster and with higher qual-
ity according to the specific instructions issued by the airworthiness and engineering
departments of the organisation. However, it soon became clear that the implementa-
tion of the new maintenance schedule was creating undue confusion and disruption
in the everyday work schedule.
Different teams were assigned unrelated tasks in the same workspace and were
tripping each other up. The sequence of work created work duplication and delays.
For instance, functional tests of the aircraft were scheduled right after it was freshly
painted, or the aircraft was to be washed right after lubrication; such cases were
creating a need for rework (­e.g., repaint or ­re-lubricate). The base maintenance super-
visor was very clearly distraught at the mess of this situation and was fervently advo-
cating for a clear separation of tasks and reallocation of human resources. Having
dedicated teams dealing with the tasks in a linear procession would be a way to solve
rework issues. However, it would also mean having workforce allocation restrictions
that would greatly reduce the capacity of the business unit to use its resources adap-
tively to fulfil requirements for other maintenance works.
As the business unit manager, taking the complaints of the staff seriously, I
assembled a team of engineers and master technicians to record and assess the work
area setup, the organisational structure chart, available resources, and work schedule
data. At first, the solution obvious to the team and me was to separate work areas and
workflows. Concurrent maintenance tasks and corrosion prevention tasks were to be
avoided; otherwise, there was a high risk for mistakes and/­or omissions. Therefore,
I initiated a study by recording the team’s findings and suggestions to determine the
best way forward. We recorded the tasks that needed to be included in the new cor-
rosion prevention schedule as a separate, detailed, and independent workflow. Charts
were created where the inputs of every step in the work were analysed: the number of
156 Ergonomic Insights

staff required, standard work times, sequence of works, necessary equipment, work
area required, facilities and amenities, safety measures, and data management.
After the team designed a new corrosion prevention schedule implementation pro-
cess, a model run was performed to collect data and create a benchmark for the pro-
cess. After comparing these data with the resources available, it became clear what
changes were necessary for the business unit procedures and workspace allocation. A
special focus was also given to the type and amount of training the staff would have to
undergo. Any shortage of equipment, inadequate safety measures, and/­or insufficient
facilities were also addressed. Overall, the approach aligned with Deming’s philoso-
phy of ­Plan-­Do-­Study-Act (­Evans & Lindsay, 2008) and Juran’s quality improvement
process (­Juran & Godfrey, 1998) and used ­best-practice quality management tools and
techniques (­e.g., process control, Pareto charts, and ­cause–effect diagrams).
Importantly, informal interviews with the staff, after every step in the process,
and brainstorming meetings with ­in-house subject matter experts played a decisive
role in the study my team performed. I formed the team, appointed a lead, facilitated
and coached them, and coordinated their activities to record and resolve the users’
requirements. I must clarify that what needed to be achieved was set in stone by the
airworthiness and engineering departments; we did not have any authority and space
to challenge this. Hence, we could only figure out by whom, where, and how that
would happen, and make it so with the optimal use of the available resources. As
typical for any ­cost-minded organisation, the changes had to be implemented with
the minimum investment in human resources, equipment, and facilities.
The whole business unit took an active part in the study, contributing to data
collection and putting forward suggestions and recommendations. The respective
conclusions and suggestions were forwarded up the organisation’s management lad-
der. In addition to the detailed report, to pass along the complete image of the situ-
ation and ensure a good understanding by the stakeholders, a campaign took place
to inform senior management about the problems that had arisen and the possible
solutions. The campaign included o­ n-site surveys and visits by the senior manage-
ment, including persons with the authority to allocate additional funds and resources.
Notably, such campaigns were outside the usual modus operandi of the organisation,
and because they required involving all the rungs of the organizational ladder, they
were reserved for special cases only.
During the campaign, one by one, upstream management realised the importance
of having a clear and precise view of the problem at hand and offered their support.
Admittedly, the organisation management culture of ownership played an important
role, making my job easier. On the other hand, it also required presenting the case for
the changes in a concise and persuasive form that could be carried along from rung
to rung to the final ­decision-makers. However, when the top brass saw the problem
themselves, it was much easier to understand the solutions offered. Sometimes, one
must put their finger into the print of the nails to believe.
Within 6 months of the start of the campaign, the organisation implemented the
suggested changes in their totality. These involved separate stages where each organ-
isational level, starting at ours (­i.e., the business unit), applied changes within their
authority. A separate work subsystem was created to deal with the corrosion issue,
assigning additional resources, providing training where requested, and allocating
Dealing with Design and Work System Flaws 157

dedicated facilities and equipment. This led to the successful resolution of the issue
at hand, with minimal delays or impact on ongoing operations, and minimised or
eliminated possible hazards.
Following the new system of work, statistics on findings and work performed
were systematically collected, analysed, and fed back to the airworthiness and engi-
neering departments. This way it was possible to verify and validate the successful
resolution of the issue, both regarding the technical issues and the process improve-
ment. The implementation was gradual and involved the inclusion of both external
and business unit resources, adjusting the responses and updating the process poli-
cies along the way.
The primary lesson from this case is that the active involvement of all stakehold-
ers in the chain of operations was the key to the successful resolution of the problem.
The ­front-line stakeholders are often those with the clearest and most precise view of
the issues faced. Their intuition and perception can offer the required solution, and
this ­co-ownership of the solution facilitates its implementation. Also, the provision
of accurate information about the problem and suggested solutions to those with the
authority to make changes is essential; it should be undertaken in a way that these
persons also take ownership of the need for changes.
Admittedly, an organisation’s culture and structure are quite often difficult to
steer in a different direction, and organisational size correlates with increased dif-
ficulty. Moreover, sweeping changes imposed by external actors are rarely met with
open arms and broad acceptance. Creating a culture of participation throughout the
organisation has multiple returns and is a prerequisite for success.

UNDETECTED DESIGN AND WORK SYSTEM FLAWS

In contrast to the case above, there are instances where the actors might fail to antici-
pate and prevent the escalation of a problem. Omissions or oversights during the ini-
tial design phase can create hazards downstream. These may take quite some time to
surface, whether in the system or a process. Within the same organisational context
described in the case above, refuelling activities were part of our daily routine in the
business unit supporting flight operations and servicing aircraft. Work of this kind
presents inherent hazards due to the nature of the materials handled. For this reason,
staff performing such tasks is specifically trained for handling these hazards, and
there are stringent safety measures in place (­USAF, 2008).
It is a standard practice in the civilian (­FAA, 2021) and military (­USAF, 2008)
sectors to use fuel pressure systems, especially where a high volume of fuel is moved.
The fuel hoses used in aviation are manufactured to specific standards (­USDD, 2011)
and submitted to rigorous testing to ensure safety during their use. Also, the operation
and maintenance of aircraft fuelling equipment are usually strictly controlled, with
the respective procedures codified in checklists and, sometimes, in legislation (­NYC,
2014). These procedures assume a standard mode of operations and specific aircraft,
trucks, and hoses (­FAA, 1974). By mode of operations, we mean the frequency and
volume of fuelling component use, both daily and for the duration of its service life.
Increased usage can, and usually does, lead to increased maintenance requirements.
Edge cases where the system is within design scope, however marginally so, can
158 Ergonomic Insights

reveal hazards that should have been considered in the initial design of the system
and associated procedures, but were not.
In our case, flight operations were of high frequency, and the turnaround time
was quite short; each time, the aircraft should be refuelled as soon as possible. As
such, the daily number of fuelling operations was high. The aircraft were serviced
by a small number of fuelling trucks, operated by specially trained staff. The latter
worked according to established procedures to unreel the hoses, take safety precau-
tions, fuel the aircraft, and reel and stow the hoses. The design characteristics of the
trucks required manual operation of the reeling drum since there was no motor pro-
vided to power the reel; this significantly increased the operators’ workload.
The frequent use of equipment led to increased fatigue of the hoses due to repeated
bending and kinking. This created points of highly concentrated stress and fatigue in
a specific part of the hose, which led to the delamination of its layers and localised
material failure. An incident due to such delamination involved the failure and burst-
ing of one hose during a fuelling operation. Fortunately, the failure was contained, and
no other damage occurred, thanks to the safety measures in place, precautions and
instructions that must be understood and applied during operation and maintenance
to ensure personnel safety and protection of the equipment, and personnel training.
The incident investigation determined that all the mandated procedures had been
followed, and the staff performed all operations as described in the operating manu-
als and checklists. Also, the safety valves and devices, both on the aircraft and the
truck, worked as intended, and all systems had been properly maintained. However,
the hose failed, and the question of why it happened so lingered. After studying
the design specifications of the fuel trucks and the hose itself, it was determined
that the one in use was ­semi-rigid and hard to bend (­USDD, 2011). Its type con-
formed to the general specifications and standards; it had been widely used in fuel-
ling trucks without any problems reported. Nonetheless, the investigation revealed a
series of factors in this type of truck that contributed to the hose failure.
The finding pointed to a failure in the initial design of the hardware by the origi-
nal equipment manufacturer (­OEM) and a failure in the design of the operating and
maintenance procedures. More specifically:

• This type of hose had a minimum bending radius requirement that made its
reel large and heavy.
• The allotted space for the reel in the truck was barely adequate and did not
make hose storage easy.
• Manual operation of the reel and the frequency of daily use were tiresome
for the staff.
• There was no arrangement to make the hose’s stowing position unique.
• There was no consideration about the weight of the hose to make it more
easily handled.
• The checklist did not describe the correct way to stow the hose.
• There was no notification for the staff to avoid kinking the hose and fully
reel it in to ensure it did not bend in the wrong way.
• The maintenance instructions required regular inspections with ­on-condition
repairs, but no maintenance records were kept.
Dealing with Design and Work System Flaws 159

Indeed, during equipment design, the OEM followed standard practices and used
generic specifications from the technical perspective. However, the OEM had not
considered human engineering aspects (­USDD, 2020) because the design did not con-
sider the frequency of use along with the task difficulty and demands. It did not
account for hindrances to operations due to the poorly designed stowage area and
the reel size and weight. Moreover, the lack of a unique stowage position for the hose
pressure coupling forced operators to simply deposit it in the stowage area, kinking
the hose in the process. The manual operation of the reel was assumed to be manage-
able by the designer, without paying attention to staff workload and fatigue. There
was no support scaffold to take on the hose weight during reeling. The combination
of weight, the difficulty of handling, and the narrow space did not afford the staff
time and physical and mental resources to attend implications from the reel operation
or the hose stowage.
On the side of organisational procedures, staff was not trained to take special
care of hose stowage. The inspection and maintenance schedule conformed to
generic requirements but did not anticipate the increased wear and tear due to the
high frequency and volume of fuelling operations. No inspection and maintenance
data were available, meaning that no trend analysis of past failures could be per-
formed. Technical risk management was minimal as it did not encapsulate additional
or exceptional failure modes applicable to the organisational context of operations.
To give everyone their due, considering these failures, the organisation took steps
to rectify the problem, as much as possible. Some of these steps were taken under my
authority, including staff training and process improvement. Equipment modification
and quality policies required getting the quality assurance and engineering depart-
ments involved. The result was to mitigate certain risks, avoid some, and accept
those that could not be done away with. Not all hazards were economically feasible
to address at the equipment level and, consequently, were addressed at the process
level. Some risks were simply accepted as a cost of operations. More specifically:

• Equipment was modified to force a unique hose stowing position (­­poka-yoke2)

(­Evans & Lindsay, 2008), which prevented kinking of the hose.
• A scaffold was added to support the hose’s weight while reeled and stowed,
reduce the staff workload, and keep the bending radius within limits.
• Staff was trained to avoid bending and kinking the hose, making sure that
they understood the hazards that these actions introduced.
• Notes were added to the checklists and documentation to outline the haz-
ards arising during operations.
• The inspection and maintenance schedule included ­record-keeping for trend
analysis.

The main lesson from this case is that when OEMs fail to include human engineer-
ing in their initial equipment design, problems will emerge during its operation. The
equipment in use in aviation is costly, and its initial design and procurement might
have taken place years if not decades before its current use. Not all usage cases

2 https://­asq.org/­­quality-resources/­­m istake-proofing
160 Ergonomic Insights

might have been considered, or the design scope might have changed, but not the
specifications themselves. Regarding the fuelling truck, instead of making the sys-
tem ­user-friendly, the OEM adhered to its technical specifications but made it cum-
bersome and tiring to work with. This led to staff not being able or willing to put
extra effort to prevent hazards, which ultimately resulted in the failure of the hose.
Consequently, the safety of staff and equipment and the health of the workforce were
compromised by the initial design flaws, even though the organisation has had rigor-
ous health and safety policies.
The second lesson regards the options when design flaws are identified. Although
it makes a case for replacing them, this is not always operationally feasible or finan-
cially affordable. In these cases, risk management and process improvement tools
and techniques can be applied to tackle the inherent hazards. Creating proper pro-
cedures and training the operators could be the most obvious risk controls, but engi-
neering measures should precede. Each risk management strategy [i.e., avoidance,
mitigation, transfer, or acceptance of risk (­ISO, 2018)] has its own set of pros and
cons relative to the hazards faced. Choosing the most effective one or combining any
of the risk management strategies to improve operations can often be the determina-
tive factor between failure and success.

CONCLUDING REMARKS
I believe the lessons shared through these two cases are applicable to any industry
sector, regardless of the level of technology used and the type and size of operations.
Ownership of tasks by the workforce should be one of the primary goals of manage-
ment. Training employees to demonstrate a genuine interest in solving workplace
problems early and removing hazards when first identified is an investment, with sig-
nificant returns.3 For this to happen, organisations must cultivate a work environment
and culture where employees do not hesitate to report problems and know that the
solutions that they suggest are given objective and unbiased consideration. Design
of equipment and systems of work should reflect actual uses, and edge cases should
be considered, as far as possible, to address hazards and manage risks. The end goal
should be to learn how to succeed repeatedly and turn any failure into a success.
As Henry Ford said, “­Businesses that grow by development and improvement do
not die” (­Ford News, 1923).

REFERENCES
EDA. (­2021). EMAR 21–Certification of Military Aircraft and Related Products, Parts
and Appliances, and Design and Production Organisations (­Edition 2.0). Military
Airworthiness Authorities Forum, European Defence Agency. https://­ eda.europa.eu/­
docs/­default-source/­documents/­emar-21-edition-2-0-(­approved)-30-march-2021.pdf
EU. (­2014). Commission Regulation No 1321/­2014 of 26 November 2014 on the Continuing
Airworthiness of Aircraft and Aeronautical Products, Parts and Appliances, and on the
Approval of Organisations and Personnel Involved in These Tasks, OJ L 362, 17.12.2014,
­p. 1–194. https://­eur-lex.europa.eu/­legal-content/­EN/­TXT/?uri=celex%3A32014R1321

3 https://­global.toyota/­en/­company/­­vision-­and-philosophy/­­production-system/
Dealing with Design and Work System Flaws 161

EU. (­2018). Regulation 2018/­1139 of the European Parliament and of the Council of 4 July
2018 on Common Rules in the Field of Civil Aviation and Establishing a European
Union Aviation Safety Agency, and Amending Regulations (­EC) No 2111/­2005, (­EC) No
1008/­2008, (­EU) No 996/­2010, (­EU) No 376/­2014 and Directives 2014/­30/­EU and 2014/­
53/­EU of the European Parliament and of the Council, and Repealing Regulations (­EC)
No 552/­2004 and (­EC) No 216/­2008 of the European Parliament and of the Council and
Council Regulation (­EEC) No 3922/­91 (­Text with EEA relevance.). OJ L 212, 22.8.2018,
­p. 1–122. https://­eur-lex.europa.eu/­legal-content/­EN/­TXT/?uri=celex%3A32018R1139
Evans, J. R., and Lindsay, W. M. (­2008). Managing for Quality and Performance Excellence
(­7th ed.). Thomson South-Western.
FAA. (­1974). Aircraft Ground Handling and Servicing - –Advisory Circular (­AC) 00-34.
United States Department of Transportation, Federal Aviation Administration. https://­
www.faa.gov/­documentLibrary/­media/­Advisory_Circular/­AC_00-34A.pdf
FAA. (­2018). Aviation Maintenance Technician Handbook–General (­ FAA-H-8083-30A).
United States Department of Transportation, Federal Aviation Administration. https://­
www.faa.gov/­regulations_policies/­handbooks_manuals/­aviation/­media/­amt_general_
handbook.pdf
FAA. (­2021). Aeronautics and Space 14 CFR § 23.2235-2245. Government Printing Office,
United States Department of Transportation, Federal Aviation Administration. https://­
www.ecfr.gov/­current/­title-14/­part-23/­subpart-C/­subject-group-ECFR5f1d2bf5cc2f06c
Henry Ford (­1923, Feb 15). Ford News, p.2.
ISO. (­2018). Risk Management – Guidelines (­ISO/­DIS 31000:2018), International Organization
for Standardization.
Juran, M., and Godfrey, A. (­ 1998). Juran’s Quality Handbook (­ 5th ed.). McGraw-Hill
Companies, Inc.
NYC. (­2014). Fire code, ­ Chapter 11. New York City Fire Department, United States.
https://­w ww1.nyc.gov/­a ssets/­f dny/­p dfviewer/­v iewer.html?file=Chapter-11.
pdf&section=firecode_2014
PMI. (­2021). A Guide to the Project Management Body of Knowledge (­PMBOK Guide) (­7th
ed.). Project Management Institute. https://­ www.pmi.org/­ pmbok-guide-standards/
­foundational/­PMBOK
USAF. (­2008). Technical Manual Ground Servicing of Aircraft and Static Grounding/­Bonding
(­to 00-25-172). Office of the Secretary of the Air Force, United States Department of
Defense, United States Air Force.
USDD. (­2011). Detail Specification: Hose Assemblies, Rubber, Fuel and Nonpotable Water, with
Reattachable Couplings, Low Temperature, General Specification for (­MIL-DTL-6615G
(­W/ AMENDMENT 1)). United States Department of Defense.
USDD. (­2020). Department of Defense Design Criteria Standard: Human Engineering
(­MIL-STD-1472H), United States Department of Defense.
USDS. (­2021). Foreign Relations 22 CFR § 120.38. Government Printing Office, United
States Department of State. https://­www.ecfr.gov/­current/­title-22/­chapter-I/­subchapter-
M/­part-120/­section-120.38
 14 Stuck in a Holding
Pattern
Human Factors Training
Development for Sports
and Recreational Aviation
Claire Greaves and Reuben Delamore
Tactix Group

CONTENTS
Our Overall Approach............................................................................................. 165
Are You Fit to Fly?.................................................................................................. 166
Managing Threats and Errors, Rush, and Risk....................................................... 168
References............................................................................................................... 177

Sports aviation as a sector of the Australian aviation industry that covers almost
half of the aircraft operations in Australia (­Civil Aviation Safety Authority (­CASA),
2021). As of 2016, sports aviation involved about 40,000 participants, more than 9,000
aircraft and 360,000 parachute jumps, and included a range of activities involving
manufacturers, training facilities, competition participants, and enthusiasts. Sports
aviation is varied and covers ultralight and ­weight-shift microlight aircraft, gliding,
gyroplanes, hang gliders and paragliders, recreational unmanned aircraft (­including
models and drones), parachuting, warbirds, ­amateur-built and experimental aircraft,
and recreational ballooning. Perhaps the most distinguishing feature of this sector
is the different motivations to participate in its activities. Although many regular
public transport (­RPT) pilots, cabin crew, and other associated staff probably share
the same affinity for aviation, aspects such as enjoyment, fun, performance, risk,
‘­r ush’ (­Buckley, 2012; Pauley et al., 2008), or grabbing opportunities may not be the
primary purpose for their engagement. These concepts associated with motivation
are what sets sports and recreational aviation apart and are the crux of the challenge
in creating tools for training and interventions for this sector.
Sports aviation clubs recognised that between 70% and 80% of their accidents
involved some type of human error. Prompted in part by findings from a series of
incidents investigated by the Australian Transport Safety Bureau (­ATSB) as well
as own investigations of the clubs, several sports aviation clubs began to realise
their members needed training, and this training needed to address their unique

DOI: 10.1201/9781003349976-14 163

164 Ergonomic Insights

risks. Although systems thinking would encourage operators to look more broadly
throughout the organisation to resolve these risks (­e.g., design and integration of
equipment, systems, procedures, processes, and people), training and our human
capabilities remain often the last line of defence that operators fall back on. This,
however, assumes that training is effective in building knowledge and skills for all
groups involved. To achieve such effectiveness, we collaborated with various sports
aviation organisations to develop a series of e­ -learning modules. At that point, we
were only tackling the knowledge aspect to help operators better understand their
capabilities and limitations and what they can do to perform safely while enjoying
their activities.
Interestingly, we noticed that the human factors (­HF) and ­non-technical skills
(­NTS) training packages landing on our desks from various operators appeared to be
similar, despite the wide and varied nature of the activities, motivations, and environ-
ments. This suggested that the nature of the risks that the operators were attempt-
ing to manage were different, yet the training was not. Our senior management had
concerns regarding the high accident rate in the sports sector, and HF was perceived
to be a significant gap contributing to the accident rate. For us and some of our super-
vising teams, there was a general feeling that HF training had become a ‘­one size
fits all’, where the application of key concepts (­e.g., fatigue, stress, d­ ecision-making,
and managing threats and errors) was not addressing the specific or unique activities
that a particular operator or organisation performed. Indeed, the identification and
integration of operational, individual, and environmental risks in the training pro-
gramme seemed to be lacking. Hence, we asked ourselves ‘­Shouldn’t the training be
adapted to meet the unique needs and risks associated with each?’.
To set the scene, the onset of NTS training within the aviation industry was pri-
marily driven by a series of accidents and incidents that led to changes to inter-
national airline regulations. These changes arose from the recognition that pilots
required training to combat key areas underpinning the series of unfortunate events
leading to accidents (­e.g., cockpit power gradients) and not just technical skills and
knowledge. Training in NTS (­also known as soft skills) in the form of crew resource
management (­CRM) has since been an integral and legislatively required1 part of
cockpit operations, even extended to cabin crew.
Most often, NTS training in the aviation industry focusses on those areas most
critical to the safe operation of the flight, including crew coordination and coop-
eration, effective communication, d­ ecision-making, conflict and error management,
stress and workload management, maintaining attention and vigilance, managing
automation, and optimal situational awareness. However, although these skills are
often ubiquitous across aviation sectors, their application is often not tailored to each
context. Indeed, a focus on compliance with regulations might have led to poor appli-
cation of training due to not considering specific risks of organisations or operational
contexts and the required skills. There are a variety of activities and tasks performed,
differing motivations or p­ erformance-shaping factors due to the operating environ-
ment, d­ ifferent-sized organisations in terms of personnel, and financial capacities to
invest in training.

1 See for example Part 119 of the Civil Aviation Safety Regulations 1998.
Human Factors Training Development 165

However, from a regulatory perspective, the level of guidance to develop train-

ing is limited by the sheer vastness of operations and unfeasibility of creating
and tailoring advisory materials to everyone. As a result, CASA has invested its
expertise in creating resources and materials that operators could use as a bench-
mark from which to tailor their training packages to their operational risks and
needs (­CASA, 2020). At least, that was the intention. What seemed to arise in
industry training, however, was a uniform and homogenised application of key
NTS concepts.

OUR OVERALL APPROACH

To begin, we needed to revisit the starting point to create or ­re-build an existing draft
of a sports aviation training package. We worked with the internal communications
and training development teams to understand the task and review what had been
developed and presented previously. At this stage, the internal development team
had been working in isolation from ­end-users, domain experts, and HF specialists,
churning through the guidance material for HF training and reflecting that informa-
tion in a ­presentation-style format. While we were sitting behind our office desks
contemplating the development of this HF awareness training package, we realised
that something was different about this group and their needs.
Our review of the initial draft developed by the training team identified what
we were concerned about, another carbon copy program based on an RPT training
model. We knew if we did not intervene and promote the tailored r­ isk-based training
approach (­i.e., making the training applicable to their risks), it would not be fit for the
users. RPT training models are based on operations of transportation that provide a
service from place A to place B. They do not account for fun and games at point X in
between those destinations that the audience of our sports enthusiasts were seeking.
It needed to be punchy and hit the mark on the risks that the sector had identified
due to recent incidents and ­near-miss events, as well as reflect what they were doing.
Also, the training should be ­cutting-edge and engaging. We felt the traditional train-
ing development approach of leveraging from RPT organisations would neither cap-
ture what the key issues were for the domain nor the activities they were performing
(­e.g., not being ­multi-crew operations).
To bridge this gap, we requested the involvement of industry representa-
tives in developing and reviewing the package through forums. We received
positive responses from several sports and recreation federations and groups.
Simultaneously, we reviewed the incident data of the ATSB, which was also bol-
stered with information from various sports and recreation federations. We found
that published information was, at times, limited regarding the factors that con-
tributed to the incidents. The review of the data and incident reports indicated that
a generic approach to developing the NTS training, based on the guidance mate-
rial alone, would not easily translate to sports aviation activities, environments,
or equipment. The context of the operations was different. These aviators were
enthusiasts who often built their own equipment and maintained it. ­Multi-crews
were a rarity, and the knowledge base and performance capabilities of the aircraft
and operators were wide ranging.
166 Ergonomic Insights

Therefore, the training needed to reflect the gaps in the intended user’s knowledge
and, most importantly, the nature of their specific risks. From our review of the data
and information collected, five key areas were identified:

• Fitness to fly
• Situational awareness in aircraft operation and maintenance
• Individual and stakeholder communications
• ­Decision-making
• Managing the potential for errors and accidents

In the next sections, we describe two cases where we applied a r­ isk-based approach
to developing a bespoke e­ -learning training package for the sports and recreational
aviation sector. We were enthusiastic to see how an innovative approach and slightly
rebellious style of getting messages across could refresh training programs in this
space.

ARE YOU FIT TO FLY?

One topic we wanted to focus on for the training package was the key areas of health
and ­well-being, which were critical to impacting or derailing sports aviation enthusi-
asts. In our review of the literature and incidents sourced from ATSB, various sports
aviation clubs, and CASA, we identified that health events (­e.g., heart attacks) and
health status (­e.g., underlying chronic disease, such as diabetes) seemed to underpin
some incidents/­accidents. Within the broader context of sports aviation, the physical
health requirements remain less rigorous than the commercial ­end-­of-town possibly
because the nature of the sports aviation sector and its risks are not uniform. For
instance, older aviators, who may be more susceptible to ­age-related health problems
(­e.g., heart disease or diabetes), can be found more in some specific s­ ub-categories of
sports aviation, such as Warbirds.2 Also, while medically prescribed drugs can play a
role in performance, the use of ­non-prescription drugs can also impact performance.
Several clubs provided information and images from their incident databases with
case study examples as a starting point to identify the need for a tailored training
package. We wanted to provide a level of knowledge of how these factors could affect
flight safety, and we focussed on the performance margins in this space. We reviewed
various ATSB incidents and case examples provided by operators, and we extracted
contributing factors associated with health for inclusion as topics within the module.
Additionally, we reviewed the respective literature (­e.g., age, fatigue, and drugs).
Moreover, having recognised earlier it was not about a ‘­­one-­size-­fits-all’ solution,
while developing the training package, we had ongoing and regular consultations
with the members from various groups (­e.g., ballooning, gliding, warbirds, and para-
chuting) and respective regulatory inspectors. We also sought advice and insights
from internal organisational medical specialists about demographics, the nature of
issues witnessed, and their concerns. These parties provided review and feedback to

2 https://­australianwarbirds.com.au/
Human Factors Training Development 167

support the drafted modules and online versions before the latter was incorporated
into the overall HF package for release.
Admittedly, the broad spectrum of sports aviation ­sub-sectors made it difficult
to tailor content to each s­ ub-category and make it exclusively relevant for the cor-
responding pilot profiles. We struggled to find a pertinent ‘­middle ground’ to ensure
user interest in or engagement with the module. Warbirds, for instance, are older
aircraft requiring focussed maintenance, and their pilots typically resemble RPT
operators with high knowledge and awareness of NTS and airmanship. These pilots
are likely to be older but very aware of the effects of age and prescription medica-
tions on performance. ­Non-prescription drugs may not be as relevant to this group,
just as ­age-related chronic health conditions may not be the most representative of the
demographic of wingsuit operators.3
Perception also plays a pivotal role. Who is to say that the warbird operators are
not all into n­ on-prescription drugs? What about issues of dehydration or medical
devices (­e.g., pacemakers) and operating for long periods of time? Stereotyping
and bias lead to generalisation about the persona of the operators. Those types of
heuristics help in creating a general training course, but you do need to be careful.
­Self-report biases play a role in the perception of the type of people and the type of
activity that they are undertaking and can lead us to assume and extrapolate about
what they do or do not do in other aspects of their lives.
Considering these variables, we took the approach of a broad brushstroke with
widespread ­sector-relevant examples: what is applicable or relevant to the wider
group? That way, we were not removing content that could be useful and important
to some but not others. We felt it would be best to be inclusive and discuss topics that
were applicable to the wider audience (­because we really did not know what people
were doing in their personal time). Ideally, at the start of the training course, provid-
ers would be able to select the sports aviation s­ ub-sector(­s) most applicable to each
trainee. Then, the modules presented would be those identified through the literature
and incident analysis pertaining to the risk profile and operational considerations of
that ­sub-sector(­s).
Indeed, a refined approach would likely lead to better engagement and hopefully
avoid people skipping through content in which they were not interested or felt does
not apply to their specific training needs. This can be a key limitation of online
training, hitting the ‘­next’ button hoping to get to something useful or applicable.
Unfortunately, at the time, we did not have the scope and time to tailor the mate-
rial at that level, which would have enhanced the module substantially. Another
principal constraint for the ­e-package was the method of learning (­i.e., remote and
­self-directed) and genuinely engaging the audience without relying on facilitation
skills in a f­ ace-­to-face delivery mode. It was challenging to envision how we would
do that. The principal challenge with ­e-learning is that you cannot present the mate-
rial like a slideshow because there is no one there to provide the context. It must stand
alone and do that well.
Moreover, although we engaged sufficiently with our audience and stakehold-
ers, a more targeted integration plan for engaging users and having their input

3 https://­www.raa.asn.au/
168 Ergonomic Insights

weaved throughout the build phase would have facilitated a more robust solution.
User engagement was attended at the drafting stage, but by then we, as creators,
had already taken the content in a certain direction; perhaps, this rendered it more
difficult for people to feel they could provide honest feedback. Next time, we would
bring a variety of sector representatives into a physical or virtual room to discuss the
­big-ticket items and c­ o-design the training modules in a more integrated manner.
Also, from a user representation perspective, it would be valuable to include a wider
­cross-section of the group including various sector activities, ages, and experience
levels. The more diverse the representative sample is, the more likely the product will
meet their needs.
It is hard to answer the question about what worked well or not with this mod-
ule. Nonetheless, we received some excellent feedback on the module content and
presentation, and it was certainly well received by the club members. We do recall
discussions around age and drugs. One could conceivably include a myriad of topics
in an HF and NTS course. What we wanted to target was this idea of a ‘­­risk-based
approach’, which was not seen in this aviation sector at the time. Rather than grabbing
generic topics of HF off a website or toolkit, our approach required drawing upon
general information and working with users and stakeholders to determine what is
relevant, of high priority, or perceived as presenting the highest risk to operations, the
safety of others, and performance. From a consultant perspective several years ago,
it would be interesting to know whether the sector is still using this training as part
of their club memberships and if not, the reasons why to inform and enhance future
training development.
Reflecting on this experience, there are several key takeaways. What tops the
list is to be mindful of perception and stereotype bias. Speak to your audience, the
users, stakeholders, and subject matter experts (­SMEs). Instead of making assump-
tions about the group, engage them early and throughout the project to ensure that
what was agreed upfront made its way into the final design/­deliverable. Secondly,
capture user needs and issues using a register. This allows us to trace the original
problem and how we have addressed it by way of our intervention. Finally, touch
on important topics and use data to inform the focus areas. It is essential not to
get caught in a ‘­­user-led’ approach. Minimise influences by others’ views on what
the sector or group is doing and what it faces. Stakeholder engagement is key, and
different stakeholders, including users and SMEs, can have divergent perspectives.
­User-centred consultation is critical, and understanding the activities and tasks they
are performing is fundamental as a skill set and tool to HF practitioners.

MANAGING THREATS AND ERRORS, RUSH, AND RISK

To help navigate through this part of our chapter, we first need to delve a little into
the background of two key models: Threat and Error Management (­TEM) model and
adaptations on the Dynamic Safety Model. As a concept and tool, TEM originated
from the Line Oriented Safety Audit (­LOSA) program, a collaborative partnership
between Delta Airlines and the University of Texas.4 LOSA was originally developed

4 https://­www.faa.gov/­about/­initiatives/­maintenance_hf/­losa/ ­history
Human Factors Training Development 169

to evaluate the performance of NTS training, through the observed application of

CRM skills and behaviours among RPT flight crews. The audit tool was later devel-
oped to capture crew errors and error management, and the TEM framework evolved
further, benefitting from research and the developing understanding of the interplay
between human performance and safety within operational environments. Key con-
tributors to this broader research included Rasmussen (­1980, 1982, 1997), Helmreich
(­2000), Helmreich and Musson (­2000), and Reason (­1990, 1997). Their work gener-
ated a deeper understanding of error, risk, systems design, latent failures and human
performance at individual and team levels.
The TEM model is usually represented as a split triangular shape, comprising at
least three different levels of process and strategies to manage or mitigate threats and
error. Its structure includes two axes with time on the vertical axis (­y) and available
recovery options on the horizontal axis (­x). Standing on its point, the TEM model
represents a process that flows from the top to the bottom. The presence of threats
and risk above the model are deflected away by threat and risk management strate-
gies. The inception of a threat passing through these strategies signifies a failure. If
the threat continues through the preventative mechanisms, it may manifest into either
a systems failure or a human error. At the error management layer, these errors are
‘­trapped’, ‘­mitigated’, or ‘­avoided’ relying on action and intervention from the crew
or other supporting systems, such as automation, traffic collision avoidance systems,
and other corrective measures. The TEM framework and process consider an opera-
tion in four stages:

• ­Pre-planning,
• Day of operations management,
• Prevention of undesired aircraft states, and
• Consequence management or mitigation.

These stages are applied across all flight phases (­e.g., ­pre-departure or ­pre-planning,
departure, climb, cruise, descent, and landing). As such, TEM utility is through the
preventative management of threats, risks, and errors by using a standardised sys-
tematic approach with predetermined procedures to mitigate and manage adverse
consequences. If the preventative mechanisms fail to manage the event, the opera-
tional team members are then the ‘­final filter’ and are required to manage the situa-
tion to mitigate the consequence of the event. To support this process, CRM skills are
seen as integral tools to support human performance against the potentially adverse
impact of threats and errors.
In the model, time and options are finite and reduce in availability and utility
the further the crew progresses through the situation. This reflects the real environ-
ment; for instance, commodities and protections, such as fuel, or the altitude that the
aircraft is clear above local terrain and structures, become gradually limited with
time. The earlier in the process any issues are captured or managed, the more time
and options are available for operators to utilise to manage an unfolding situation.
Critically, TEM as a process presumes a sequential handling of threats and errors
with the benefit of ­pre-considered defences and management strategies. Realising
this was key in developing our TEM section of the training package; the history and
170 Ergonomic Insights

development of TEM indicated that its traditional form could not match sports avia-
tion well.
The problem was that TEM had been a cornerstone training subject for com-
mercial aviation since the 1990s, and our management had assumed this would also
hold true for sports aviation. For our NTS/­CRM package, we needed to ensure the
intentions of TEM were supported with practical steps, strategies, and tools that
aligned with the operators’ needs and capabilities, their equipment, their risks (­if
known), and their operating environment. This training module had been left last
for development due to the complexity we had seen when reviewing accidents and
incidents. However, we were also struggling to visualise how traditional TEM could
be applied to the unique risks of the sports aviation domain and articulated in a
meaningful way to the audience. It had become clear that incidents were not often
due to the type of systemic and latent failures typically found in the more technologi-
cally advanced ­team-based operations of commercial aviation. The sports domain
included enthusiasts who often had a hand in building their own equipment and
maintaining it. ­Multi-crews were a rarity, and the knowledge base and performance
capabilities of aircraft and operators were wide ranging. This differed to what was
seen in RPT organisations where the NTS training reflected examples focussing on
shared failures within multiple crew member interactions, advanced aircraft technol-
ogy, structured ­maintenance-based activities, and other detailed investigations into
contributory factors.
By comparison, training and education for sports aviation appeared more cursory.
It was common to see sports aviation using the same RPT incident examples in their
training. Yet, based on feedback from domain stakeholders, these examples were not
as relatable to the type of operations, actions, or events of sports aviation. Incidents
in this sector were often events involving a single person (­e.g., single pilot vs the
multiple crew members and maintenance support seen in RPT) or based on smaller
teams with less formal training and procedures. Weather and terrain events (­e.g.,
flight into terrain or losing visual reference in cloud and losing control) were fre-
quently identified as contributory factors linked to the operators’ d­ ecision-making to
continue to fly in bad weather or not follow a previously planned route. These issues
were minimised in RPT operations due to the height above terrain and the supporting
technology. Many of the risks that would effectively be unacceptable in RPT were
often not even considered a risk by some sport operators (­e.g., wingsuit pilots and
their proximity to terrain). Also, the more reactive nature of the operations (­e.g., fly-
ing at a low level in an area previously not known, to fulfil an opportunity) can pres-
ent risks the pilots are unaware of (­e.g., powerlines or terrain may lie ahead), which,
interestingly, can even contribute to the gratification of performing the activity.
The TEM concept, of course, has relevance to flying and operations in the sports
domain, but in its traditional and accepted form, it was not so clear cut for areas
like glider competitions, aerial displays, wingsuit activities, parachutes, balloons,
and hang gliders. Even a cursory review of the history and development of TEM
reinforced that the expected behaviours and motivations of RPT crews may not cor-
respond with the nature of sports activities (­e.g., opportunity fulfilment, competitive
behaviour, ­split-second timings, u­ n-tested changes to plans, increased exposure to
the risks of terrain, weather, and other unknown factors). In short, not only were we
Human Factors Training Development 171

dealing with environments, technology, and levels of training different from RPT
but also some inherent sports aviation elements seen by RPT crews as the ‘­wrong
stuff’ (­Moore, 1997). While some areas had similarities, we were dealing with a
potential misfit of TEM to sports aviation due to the nature of the operating envi-
ronment and the differing goals of the sports aviators from RPT operations. So,
where did TEM fit in? After collating the information, we presented our findings to
representatives of the domain and asked them that same question. The resounding
response from our industry partners and ­end-users was that TEM was not a good fit
in its standard form.
It was time to go back to basic principles, which is something we should do more
often as professionals to make sure we do not blindly apply guidance out of the
intended context. This activity would help us identify the limitations of the model
for the sports domain and define the problem. We wanted to find a way to tailor
TEM to the tasks and needs of sports aviation users. Our preliminary findings of
the accident and incident data and literature review indicated we should further
investigate three phenomena: firstly, the propensity and individual appetites for
risk aversion and tolerance (­Pauley et al., 2008); second, the excitement sometimes
linked to rush at the limits of individual capabilities (­Buckley, 2012); and thirdly,
competition. These drivers and motivators appeared to be key differences between
sports aviation and RPT.
We needed to find a way to incorporate these phenomena into the traditional TEM
concept. Earlier discussions with e­ nd-users and the information from our literature
review had also prompted the recollection of a presentation provided by the Royal
Aeronautical Society and the London Metropolitan University in 2005 based on
Rasmussen’s (­1980) work on systemic accident analysis and Cook and Rasmussen’s
(­2005) work on safety and drift. The presentation had illustrated accident causation
as dynamic and constantly in flux, an approach that we needed to explore as a pos-
sible alternative or enhancement for the TEM package.
Although the Dynamic Safety Model (­Cook & Rasmussen, 2005) primarily con-
siders accident causality, it can also be used to find out why accidents do not happen
and then foster the repetition of those activities. This line of thought is also aligned
to more modern theories than older causation models that contributed to the develop-
ment of TEM. The Dynamic Safety Model incorporates the concepts of risk, human
performance, and external influences that may contribute to a drift of the operating
point towards failure. F
­ igure 14.1 presents our attempt to simplify the representation
and complexity of influences within the operating envelope and in relation to the
boundaries of the original Dynamic Safety Model.
The operator/­operation is represented as a point/­area inside an envelope of safe
operations and a wider ‘­bubble’ of acceptable performance. This point is dynamic,
moving within the operational envelope due to forces and ­counter-forces directed
on it from factors related to the safety, efficiency, human, operational, and other
performance boundaries of the bubble (­e.g., social expectations). At the same time,
such forces are created within the operational area itself (­i.e., because of the individu-
als making up the team and aircraft performance). Therefore, the entire operational
envelope is shaped by several layers that represent thresholds for failure and act as
sources of ‘­pressure’ (­e.g., legislation, standards, policies, technical, and weather
172 Ergonomic Insights

F­ IGURE 14.1 A simplified representation of Rasmussen’s (­1997) Dynamic Safety Model

reflecting both a safe operating point and an operating point that has drifted to failure, breach-
ing the boundary of acceptable performance.

limitations) that act on the system to deter it from reaching and crossing the accept-
able performance boundaries.
The boundary of acceptable performance provides the threshold beyond which
errors can visibly and detrimentally affect performance. At this boundary, environ-
mental, organisational, and societal opportunities and constraints create currents that
interact with local operational factors and increase or decrease the distance from
the boundaries and affect the position of the operational point. Examples of ‘­safety
currents’ can be safety programs, training initiatives, or respective technology (­e.g.,
equipment capabilities, information provided, alerts, and warnings). Conversely, rou-
tine violations and workarounds (­i.e., habitual actions that breach rules or proposed
norms but are accepted as normal work and usually related to poor design or poor
procedures) may contribute to a reduction of the operations and boundary distance.
The economic or operating boundaries represent elements such as the motivation
to cut costs and the duration and quality of tasks. The human performance boundary
relates to the task demands and human capacity. If the system pushes for optimisa-
tion, the effort of the operators maximises to get more time for less. Failure at this
threshold can occur due to overload, leading to mental and physical fatigue, and
underload or workload, creating conditions for complacency or limited vigilance.
The premise is that while the operating point moves in response to all forces and
currents, if it remains within the bubble, the operation is not likely to result in an
Human Factors Training Development 173

accident. The higher the distance from the boundaries, the lower the risks of failure
(­Morrison & Wears, 2022).
Hence, acceptable performance can represent the combination of various inter-
connected aspects, such as personal performance, goals or motivations, safety, or
even equipment performance. The margin between the envelope of safe operations
and acceptable performance boundaries represents error tolerance, which can be
engineered (­e.g., safety margins designed in equipment) or perceived. Conceptually,
this margin represents the last opportunity of operations to default to their safe oper-
ational envelope before they reach unacceptable performance (­e.g., accidents, eco-
nomic crashes, or serious health conditions).
However, the perceived tolerance is not static; it can be reduced or increased
depending on specific events. For instance, when operators breach the margin and
there is no negative consequence, the margin could be reset at a new point closer
to the acceptable boundary and, thus, reduced. Conversely, an accident experience
might lead to an increase in the error margin, meaning a narrower ‘­safe envelope’
and efforts to move the operational points towards its ‘­safe centre’. Simply put, the
closer the operating point to the boundary of the envelope, the less the available
defences and tolerance. If the failure boundary is crossed at any point, the system has
drifted into a state with adverse outcomes.
Cook and Rasmussen (­2005) later developed the idea of coupled systems within
the same model. The coupling uses controls for risk and performance that can man-
age the influences from the boundaries to a specific extent, shifting the operating
point from a ­high- to ­low-risk positions within the performance envelope far from the
boundary of acceptable performance. In RPT, maximum distance of the operational
point from the thresholds of performance is achieved through c­ ounter-currents gen-
erated by training and standards, procedures, automation and aircraft performance,
positive crew actions, risk and error management strategies, etc. The expected result
is the safe, planned, mostly predictable, and efficient flight journey, which is primar-
ily driven by a goal to minimise human interference using automation and manage-
ment of flight parameters to minimise costs (­i.e., fuel and maintenance).
The TEM model in RPT supports the ability of crews to achieve this goal through
­high-performing and trained crew operations and standards and embedded risk and
error tolerance through operational procedures and the use of technology and equip-
ment (­e.g., automation, fuel management, and aircraft performance monitoring).
Employing the TEM framework, however, requires significant time and resources
to determine what risks may exist and then develop plans to mitigate those risks.
Employing mechanisms like the ones mentioned above, even scaled down, in
smaller, mostly s­ ingle-operator environments, can present key financial or business
challenges. While safety is far from an undesired state in sports aviation, it was often
the presence of a challenge or competition, the demonstration of skill and elements
of fun that attracted the operators to pursue their activities.
The utility of the Dynamic Safety Model representation helped to make sense of
how RPT and sports aviation environments are fundamentally different. In sports
aviation, the operating point can reflect an already ­high-risk system, away from its
‘­safe centre’ (­Severinghaus et al., 2012). While some groups such as Warbirds reflect
a tightly coupled ­high-risk operation (­e.g., through procedures and planning), the
174 Ergonomic Insights

system tolerances to the margin of error and acceptable performance boundary are
minimal; in part, this can be attributed to risk and rush and the motivation of put-
ting on ‘­a good display’. Environmental factors alone push the operating point closer
to failure through reduced clearance from terrain, more exposure to weather, and
reduced performance capabilities of equipment and crew.
After we understood the differences between the two sectors, we started develop-
ing a TEM approach that focusses less on s­ystem-based preventions and more on
active mitigations operators could consider. In pitching this concept as an alternative
to the traditional TEM model, the ­end-users and stakeholders agreed that the diver-
gence between their activities and RPT stemmed from the following features:

• The primary motivator for the activity is for fun, not commercial gains as
in RPT operations.
• It is about experiences and opportunities, not necessarily getting from one
point to another. Opportunities can arise at any time, and pilots have the
freedom to change plans.
• In some environments, there is a thrill in pushing their aircraft limits, chal-
lenging themselves, and experiencing the adrenaline of flying.
• Competition flying may prompt the need to put into place a plan last min-
ute without the opportunity for a detailed review to account for risks and
unknown factors.
• Pilots are more affected by the environment they are flying in, both physi-
ologically and in proximity to the terrain.
• In some environments, there is a goal to ‘­put on a show’. This requires
significant planning and communication, while also maximising the audi-
ence’s perception of risk and thrill.

Coupled with confirmation from our stakeholders, we felt that we had enough of an
understanding of the differences among activities, their risks, and the applicability
or not of the models for the different operational environments. While not always
actively seeking risk, nor with an intent to be exposed to risks, many of the activities
undertaken in sports and recreation aviation naturally had a reduced margin or toler-
ance for error. While safety was a desired outcome, that is not the same as saying it
was the goal of the activity. Thus, we merged efforts to reframe the intent of the TEM
model to consider these factors, focussing on awareness and the use of practical tools
and strategies to manage or mitigate the risks related to the goals of sports flights
(­competition, enjoyment, etc.), risk perception, reduced separation from structures
and environmental threats, and the reliability and capability of aircraft.
Upon reflection, we evaluated a unique environment in a structured way and
involved e­ nd-user and industry stakeholders in the module design, who were now
championing its value. We had achieved what we were trying to get other operators
to do, that is, tailor training to meet and address their own tasks and ­activity-specific
risks. But we made one mistake; we had not involved everyone. While working on
this project, internal stakeholders had shifted and reorganised, and our reporting
lines changed. We had not been as judicious as we should have been due to infre-
quent, and, in hindsight, ineffective communication with our internal stakeholders.
Human Factors Training Development 175

Our previous reporting lines had been directed into an area with a detailed under-
standing of what we were trying to do and familiarity with the concepts we were
managing. While for us, the understanding and need to apply TEM in a tailored
way were clear, we struck a challenge to explain the concepts we were addressing
to team members not familiar with the area. There was distrust in the new approach
as TEM was normalised by many as the way to manage any operation. Who were
we to change such legacy training content? We began to feel ­under-supported by the
internal team primarily because of the difficulty we had in explaining the customised
model in a simplistic and accessible way (­i.e., ­non-HF jargon).
We were under immediate time pressure to deliver the final product for internal
and external stakeholders. The time limit was internally imposed and linked to a
perception that the models and concepts were solely our academic musings, and there
was a need to correct the approach back to TEM as applied to RPT. Consequently,
the intended content of the module was lost as the focus became achieving deliv-
ery, r­ e-writing the section in line with TEM legacy training, and managing internal
stakeholder perceptions. At the time, the concepts made sense to us and were based
on sound HF principles, research, and user engagement. However, the concepts did
not make sense to everyone else. The management team had no appetite to review
the suggested approach nor the research and information that had taken us there.
Our failure to communicate effectively and manage internal stakeholder expecta-
tions let us down. Eventually, we made them understand that we had not invented the
approach or made it up. Then, the feedback we received was simply that our approach
was ‘­too new’, ‘­too novel’, and not widely accepted to be published by the organisa-
tion. The experience took some time to get over.
There are some great lessons learned here for all HF practitioners. We were too
caught up in our focussed enthusiasm for what we were working on; at the time, we
thought success was eminent. Had we applied a more proactive internal stakeholder
management process and incorporated critical thinking about key organisational
psychology principles around organisational and culture change, we may have bet-
ter articulated our approach to the broader audience and enjoyed a successful out-
come. In the early roadshows, where we had been communicating what we were
developing for the sector, we had been using language broadly and deliberately as
a tool to garner support from the sports aviation groups. We achieved b­ uy-in by
reinforcing the general view that the domain was different. Although the concept
of TEM was not wrong for this sector, it simply fell short of reflecting the experi-
ence of the e­ nd-user group. We were aiming to enhance the model and take a novel
approach to expand it.
Another key takeaway from the outcome of this module was to be aware of one’s
areas of expertise and knowledge and know when to park the ego. It is easy to be
frustrated and disappointed when you or the team have been working tirelessly to
deliver a quality piece of work and the feedback that you receive is less than stellar. It
is a mistake to lean away from respectful interactions with broader stakeholders. One
needs to lean in to understand another’s perspective and position so that all parties
are on the same page and work towards the common goal. Rather than ‘­throw out the
baby with the bathwater’, it may be as simple as ­re-articulating the message. For us,
our message should have been ‘­The concept of TEM works, we just need to tailor it
176 Ergonomic Insights

for this domain’. Such a statement may have been effective at working through the
miscommunication or misinterpretation that our message created, ‘­TEM is wrong,
and we are going to invent something new to address it’.
Although we did not achieve the delivery of the module that was desired by the
industry stakeholder groups, and the final product deviated from our initial planning,
the relationship building and ­buy-in with the sports sector was excellent. It was a
key example of a strong partnership and collaboration towards achieving a training
programme that would work for them even if this meant it would not incorporate
our original approach. From our experience, these lessons have taught us how to
approach the problem of applying novel theories to ­long-standing problems in a more
integrated, ­research-focussed, and collaborative way. The overarching success of our
work is that an e­ -learning training package was developed and provided to a unique
sector of the aviation industry, and the application of existing theories and models
can be adapted to novel contexts and not just ‘­the big players’. What stands in the way
of any successful training or HF intervention is that organisations and practitioners
alike need to truly understand their specific risks within their environment so that
they can tailor how they address these areas. Without this capability, no training or
intervention will suffice.
In summary, what we can advise HF and other professionals based on the learn-
ings from this case spans the following areas:

• Perform a deep investigation through proper analysis and research into an

area. This will help to understand what is important to the actual operators/­
users as to what they think they know and identify what they need to know.
• Challenge the norm. Specialists and practitioners will encounter difficul-
ties when breaking the mould or challenging the accepted thinking/­models/­
theories, especially within highly regulated environments.
• Avoid the glass tower. Language is key to successfully communicating a
message, but it can also be a key area of discomfort if not in line with the
norms.
• Apply it at your own risk. It is generally believed you can take any common-
place HF tools and apply them everywhere, in every situation. However,
tools should be selected based on their suitability to the environment and
account for the specific risks of that environment and operations.
• Deeply understand the content and underpinning science when communi-
cating potential changes for legacy knowledge. If you can communicate a
concept simply and with r­ eal-world examples, you will have more success
than us.
• Involve everyone. One pitfall of being part of a specialist area is that the
cross-pollination and collaboration among different teams or divisions
­
within an organisation can be limited. It is important to engage widely, to
consult with SMEs to ensure the suitability of the delivered product, and to
leverage the knowledge of those in other industry areas. Remember your
internal stakeholders, like, really remember them and bring them all on the
journey with you.
Human Factors Training Development 177

REFERENCES
Buckley, R. (­2012). Rush as a key motivation in skilled adventure tourism: resolving the risk
recreation paradox. Tourism Management, 33, 961–970.
CASA. (­2020). Advisory circular, AC 119-12 v1.0, Human factors principles and non-tech-
nical skills training and assessment for air transport operations, Civil Aviation Safety
Authority, Australia.
CASA. (­2021). Sports aviation, Civil Aviation Safety Authority, Australia, https://­www.casa.
gov.au/­aircraft/­sport-aviation/­about-sport-aviation (­accessed August 2021).
Cook, R., & Rasmussen, J. (­2005). “­Going solid”: a model of system dynamics and conse-
quences for patient safety. BMJ Quality & Safety, 14(­2), 130–134.
Helmreich, R. L. (­2000). On error management: lessons from aviation. BMJ, 320(­7237),
781–785.
Helmreich, R. L., & Musson, D. M. (­2000). Threat and error management model: components
and examples. British Medical Journal, 9, 1–23.
Moore, J. (­1997). The Wrong Stuff: Flying on the edge of disaster. Specialty Press.
Morrison, J. B., & Wears, R. L. (­2022). Modeling Rasmussen’s dynamic modeling problem:
drift towards a boundary of safety. Cognition, Technology &Work, 24, 127–145.
Pauley, K., O’Hare, D., & Wiggins, M. (­2008). Risk tolerance and pilot involvement in haz-
ardous events and flight into adverse weather. Journal of Safety Research, 39, 403–411.
Rasmussen, J. (­1980). Notes on human error analysis and prediction. In Synthesis and analy-
sis methods for safety and reliability studies (­p­­p. 357–389). Springer, Boston, MA.
Rasmussen, J. (­1982). Human errors: taxonomy for describing human malfunction in indus-
trial installations. Journal of Occupational Accidents, 4, 311–335.
Rasmussen, J. (­1997). Risk management in a dynamic society: a modelling problem. Safety
Science, 27(­2–3), 183–213.
Reason, J. (­1990). Human error. Cambridge University Press, New York, NY.
Reason, J. (­1997). Managing the risks of organizational accidents. Ashgate, Hants, England.
Severinghaus, R., Cuper, T., & Combs, C. D. (­2012) Modeling drift in the OR: a conceptual
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 15 Undertrained Workforce
and Poor System Designs
Jose ­Sanchez-Alarcos Ballesteros
Factor Humano

CONTENTS
Lack of Training...................................................................................................... 179
Wrong Design Sequence......................................................................................... 184
References............................................................................................................... 188

LACK OF TRAINING
This first case dates back to 2007 during my work at a nuclear power plant (­NPP).
The plant had an outstanding safety record that was boasted in industry as an organ-
isation in which almost three years had passed since the last ­non-programmed reac-
tor stop (‘­scram’, in the nuclear lingo). However, NPPs were, and still are, the subject
of political unrest. Despite their safety records, names like Chernobyl,1 Harrisburg,2
or Fukushima3 were widely known, while, at the same time, some key features of
these cases could be conveniently forgotten (­e.g., intrinsically unstable designs or
susceptibility to extreme natural phenomena).
Until 2004, in Spain, NPPs enjoyed support to navigate the concerns of political
and ecological groups. However, newer governments became openly hostile to the
nuclear energy industry. In the emerging political climate, opening a new plant was
difficult, as was sustaining those already operating. Existing plants were under the
threat of being shut down. The owners of the plants, conscious of this phenomenon,
decreased their investment in the future of NPPs.
In some cases, political fighting reached an emotive pinnacle, culminating in the
pronouncement of a ‘­­non-nuclear city’, the place where more than half of the NPP
workforce was living, although the NPP was the main economic engine of the region.
NPPs have been targets of demonstrations by ecological groups, including assaults to
NPP installations.4 In 2004, a w ­ ell-known journalist made a TV programme about
the problems with NPPs, with references to Chernobyl.5 The journalist attributed
cancer to an NPP because it appeared in three consecutive generations of a family

1 https://­en.wikipedia.org/­wiki/­Chernobyl_disaster
2 https://­en.wikipedia.org/­wiki/­Three_Mile_Island_accident
3 https://­en.wikipedia.org/­wiki/ ­Fukushima_nuclear_disaster
4 https://­file.ejatlas.org/­img/­Conflict/­2216/­­garona-­cierre-­ya-4_1_.jpg
5 https://­vertele.eldiario.es/­videos/­actualidad/­­mercedes-­mila-­diario-­centrales-nucleares_1_7787551.html

DOI: 10.1201/9781003349976-15 179

180 Ergonomic Insights

and they lived close to a plant, although there was no mention of the possible contrib-
uting genetic factors.
In September 2006, a mainstream newspaper published a f­ront-page headline
about a plant that was about to close because its operating licence was denied an
extension beyond 2009.6 The same source mentioned government intentions not to
consider an extension of the ­40-year useful life of NPPs, thus indicating a clear threat
to the existence of the remaining plants. That was the political and media environ-
ment of that period, and it can explain some things that would happen later. Things
changed after the public announcement about this plant closure, especially since
it was presumed that the newspaper had shared credible information from govern-
ment sources. After the alarming news release, the NPP suffered five scrams in a
few months, while almost three years had passed since the last one. Something was
clearly wrong at the plant, and they wanted to know what the issue was.
Due to the hostile ­socio-political environment, the management of the NPP was
aware that their practices were closely examined. Among operational concerns, they
were working on the development of transparent job descriptions to outline the key
competencies of each role. Considering the unfolding situation and political and
industrial unrest, the plant owners were decreasing operating costs, and hence, there
was a moratorium on workforce growth. Subsequently, the NPP contemplated the
recruitment of temporary workers and subcontractors, although, as explained below,
their work description would include the performance of traditional, ordinary opera-
tional tasks.
In the past, when the reactor necessitated fuel recharge, the plant could cease its
operations for four months, and the substantive workforce would perform all the
required tasks, usually with considerable overtime expenditure. It was said that when
the plant stopped, workers could buy a new car with the overtime payments. That
solution was expensive for the NPP, mostly due to the extended downtime. Hence,
major changes were introduced to reduce shutdowns to under one month. These
changes led to the massive recruitment of temporary workers.
During downtime, temporary workers were subject to surveillance by members of
the permanent workforce who were knowledgeable about the task and their related
safety issues. Nevertheless, most of the safety incidents in the plant happened while
it was closed, and they were attributed often to the inexperience of new, temporary
workers. It was common for jokes to be made about inexperienced workers, like that
they would get minor radiation traces that, once detected by the sensors, would pre-
vent them from leaving the plant until they were decontaminated by members of the
medical service dressed in hazmat ­gear – quite an alarming fashion.7
Despite these safety challenges, the practice of using temporary workers was
incrementally extended from downtime periods to ordinary operations. Eventually,
these workers became a common part of the employment landscape, not restricted
to downtime. However, it was a major difference in the legal side: justifying a tem-
porary contract was straightforward during downtime, and legal complications were

6 https://­elpais.com/­diario/­2006/­09/­17/­sociedad/­1158444001_850215.html
7 https://­img.joomcdn.net/­a0239125a608a896a3019849899decad751573e4_original.jpeg
Undertrained Workforce and Poor System Designs 181

not expected. That situation would change when temporary workers were included in
the normal operations phase.
When temporary workers became involved in routine operations, rather than just
seasonal downtime, they acquired more experience and familiarity with operational
routines. As such, surveillance strategies relaxed. Additionally, justifying why nor-
mal operations are performed by temporary workers is harder than that in the down-
time situation. An increasing pressure to convert them into permanent employees
should be expected.
That was the situation when the safety incidents started to happen. It was hard to
explain why almost three years had passed without a single scram, and they now suf-
fered from five in a short period. Although NPP managers could intuitively guess that
the media headlines and the resulting anxiety across the workforce could be related
to this, they wanted to know the technical side, that is, why did these scrams happen?
I was invited to participate as an external expert in the effort to answer this question
since I was ­well-known in the organisation. This was because of my previous work
with the NPP in the organisation and human resources field.
The session was opened by the operations manager, who explained the technical
facts to team members. In each case, he concluded with a ‘­lack of training’ expla-
nation as to why the scram happened. My limited knowledge about the technical
aspects of an NPP did not allow me to challenge the explanations. However, the ‘­lack
of training’ label was surprising, especially when it was used repeatedly.
Inescapably, the explanation was seeking a question that, in turn, would require a
clear answer. Why were the tasks leading to the scram performed by workers without
the right training? All the attendants with a technical background were surprised by
this question that could appear as rhetoric or a simple boutade. However, they caught
the relevance of the point: the problem was beyond the mistake of a worker in every
instance. Something was wrong at the organisational level.
In some way, I was playing safe by raising concerns about the ‘­lack of training’
issue because of my previous experience. At that time, I was familiar with air acci-
dents that were attributed to this cause and involved stakeholders who attempted to
move the focus away from design or organisational pitfalls. The final operator could
become the breaker of a system and the stoppage point to mask the need for major
system changes (­Ballesteros, 2007). Although system design plays a significant role
in the identification of wider issues, in this case, lack of training was real and legiti-
mate; people really were performing tasks without the qualification that would allow
them to do it! Why this organisational pitfall?
At this point, I must add more context. Labour regulations in Spain were, and still
are, extremely protective. There are several cases where a temporary worker, sup-
ported possibly by a trade union, can sue a company, forcing it to recruit the worker
as a member of its permanent workforce. Severance pay is high, and the reasons for
firing permanent workers must be carefully justified. Therefore, if the company is not
able to justify why an employment is temporary, the worker can become a member of
the permanent workforce through the decision of a judge. One of the arguments that
could be used to advocate that a worker should become a permanent employee is the
attendance of training sessions. Normally, training is provided to permanent work-
force members. Therefore, the Labour Relations Department advises managers not to
182 Ergonomic Insights

include temporary workers in training sessions, unless they can justify that training
addresses a specific activity related to the objectives of the temporary contract.
Hence, once the ‘­lack of training’ issue was raised, every piece fell into place.
Managers were using temporary workers without differentiating them from the per-
manent workforce, except for aspects that they had been advised to avoid the legal
risks. One of the industrial relations risks was training provision. Recruiting tem-
porary workers was common practice, but providing training could strengthen the
allegation that the employee should be made permanent, with ongoing benefits. As
such, those workers could claim different work conditions. Apart from the safety
briefings offered to anyone visiting the plant, additional training was not offered to
temporary workers.
This situation made clear that something should change. Subsequently, tasks were
analysed to identify ­safety-critical ones, meaning those that should be performed,
or at least closely supervised, by members of the permanent workforce. Those
tasks, if incorrectly performed, could contribute to physical or radiological damage.
Therefore, they were subject to close supervision if not directly performed by expe-
rienced workers.
Notably, working inside an NPP, even on a temporary basis, has some interesting
features. Safety is always a concern and intrinsic to operations, but it is also an objec-
tive, and the achievement of which must be convincingly demonstrated to external
stakeholders due to political pressure. For instance, to avoid false accusations, dosim-
eters (­a device to measure the uptake of external ionising radiation) remain inside the
NPP; every worker must wear them inside and doff them before they leave the plant.
In that way, it is possible to differentiate the radiation levels accumulated in the NPP
from that which might come from exposure to other sources. The possible attribution
of any sickness, mainly cancer, can be examined accordingly.
This ‘­­safety-show’, as I named it, necessitated t­ ime-consuming induction training
for everyone who entered the installation on a permanent or temporary basis. Hence,
those sessions could have been the right forum to introduce critical information with
the aim to avoid major mistakes. Still, permanent workforce members were encour-
aged to keep overseeing and mentoring the temporary workers who, despite some of
them being in the plant for a long time, had not received full training. In some way,
the plant had suffered a drift toward a decreased safety level, and the five consecutive
scrams made all the involved people more careful.
However, this initial effort was made by the experienced workers of the plant,
without organisational guidance beyond a ‘­be careful’ prompt. The identification of
the organisational issue beyond the ‘­lack of training’ should ideally drive the estab-
lishment of standard criteria about who can and cannot perform s­ afety-critical tasks.
In other words, the tasks linked to every specific job description could have been
reviewed and separated into tasks that could be delegated and tasks that should be
performed by the jobholder. In that way, the decision about what could be delegated
would not anymore be left to the judgement of each worker, and the organisation
would maintain this under control. Nonetheless, the plant kept working with the
abstract ‘­be careful’ mantra addressed to experienced workers and relied on their
supervision practices. This mixed solution revealed itself to be enough to stop the
sequence of scrams.
Undertrained Workforce and Poor System Designs 183

Indeed, the most reasonable solution should be to hire on a permanent basis those
required to run the plant and provide them with all necessary training. However,
once the political hostility was clear and public and the plant closure was more than
a remote threat, recruitment became more tightened. The owners did not want to pay
expensive severance payments if they could avoid them, especially as they knew that
the plant was to be closed and the workforce would be fired at a high cost. Adding
new members to the permanent workforce would mean an increase of a cost that, at
that moment, was a real threat.
On the other hand, temporary workers were present in the normal operations well
before the scrams. Why did the incidents not start then, and why did they appear only
after getting notice of the closure of the plant? There is not a clear answer to that, and
we can only launch a hypothesis, partially based on my impressions from my visits
to the plant before and after the alarming increase of scrams. Before the publication
of the newspaper article about the future of NPPs, permanent workforce members
were relaxed about their own job safety. Compliance with the surveillance require-
ment was informally adopted and performed in a natural way, and despite the lack of
formal training, experienced staff could explain to the temporary workers why the
tasks were designed in a specific way and the risk of doing them in different ways.
After the article was published, permanent workers possibly felt threatened, and their
minds were not precisely on the necessities of the temporary workers that they were
supposed to watch but in their own insecure situation. Therefore, the work environ-
ment could have become especially tense and prone to errors. Increasingly, more
operational tasks were delegated to temporary workers lacking appropriate training
or adequate work experience and not consistently supervised.
Within the limitations of a hostile external environment that, despite the sky-
rocketing energy costs, is still thriving,8 I consider the improvement explained above
a successful case. Admittedly, the solution was limited since some major issues
are untouchable, and it was retrospectively applied after the NPP experienced the
scrams. Nonetheless, improvements were made in two ways:

1. Improving the induction training, that is, the knowledge that anyone work-
ing inside the NPP must receive, regardless of whether the collaboration
is temporary or permanent. This training is centred on ­self-protection and
basic knowledge about radiological risk.
2. Improving the task distribution by defining in every job description the
­non-delegable tasks where an error could drive a serious safety problem if
performed by a temporary, ­less-skilled worker. It implied the inclusion of
a new section in the job descriptions, making clear which tasks could be
delegated and which ones could not.

Despite these options being enough to stop the safety incidents, they were far from
being an adequate solution, which necessitated a focus on system design and deeper
and wider organisational changes. However, this is what was feasible in the legal

8 https://­elpais.com/­e conomia/­­2 021-­11-11/­­e spana-­s e-­d esmarca-­d e-­f rancia-­y-­sigue-­c on-­el-­plan-­d e-­
apagar-­la-­energia-­nuclear-­en-2035.html
184 Ergonomic Insights

environment of Spain. Certainly, having more flexible laws about the workforce, that
is, hiring and firing according to workforce requirements as well as affordable sever-
ance payments, would make everything easier, including full training and being in
the permanent workforce.
In the playground of politics, someone must acknowledge that barriers to firing
also become barriers to hiring; that was the external trigger leading to the inter-
nal organisational issue. Therefore, the options were defined in very limiting terms.
Inside them, safety issues were solved, despite the organisational conscience about
the existence of a better solution that, regretfully, seemed out of reach.

WRONG DESIGN SEQUENCE

Designing a new aeroplane is a long and expensive process. Delays that culminated
into years beyond the initial deadline are frequent, and once certified, the manu-
facturers will try to keep the currency of the design for a very long time. There
are thousands of types of planes,9 with some of them ­brand-new, flying with a type
certificate issued in 1967. Such a certificate is issued by the authority confirming
that a plane complies with the applicable airworthiness requirements. The seemingly
dated certificates are far from uncommon; for instance, a plane that started flying in
1994 and is still in production brings an ­Intel-486 processor as one of its main IT
elements,10 that is, a processor discarded more than 20 years ago by many personal
computer manufacturers.
Curiously, in a world where technology seems to move at lightspeed, the time
since the first certification is not a good reason for a change but just the opposite.
Manufacturers stay attached to the design that received the certification for decades
and, paradoxically, along with crews and maintenance engineers who got their rat-
ings to operate or maintain a specific plane become a powerful sales argument. These
people will need only minor adaptations, instead of a full rating process for a new
design. In turn, this relates to a huge amount of monetary capital that influences the
decision about plane purchases. Hence, a type certificate is intended to last, and it is
important to get it right from the beginning. Thus, the certification process must be
meticulous because the design could be sustained for years.
Every system, piece, and its use and maintenance must be accepted by its merit
and per the potential interactions with other elements. As this process of analysis is
complex, it employs quite often the ‘­similarity resource’, that is, asking for the accep-
tance of something that has been previously used in other certified planes. The pro-
cess becomes even more complex when several agencies are involved in the approval
of a product, especially if it is intended to be sold and fly worldwide. This can include
the European Aviation Safety Agency on behalf of Europe, the Federal Aviation
Administration on behalf of the United States, and the agency of the country of
manufacturing. Agencies that do not automatically accept the certificate by other
regulators must approve the design and, despite the existence of mutual approval
agreements, a favourable decision cannot be taken as granted.

9 https://­simpleflying.com/ ­­boeing-­737-­in-­service-stored/
10 https://­www.airliners.net/­forum/­viewtopic.php?t=757423
Undertrained Workforce and Poor System Designs 185

Large countries with huge internal markets can afford the certification of planes
for internal flights (­e.g., the Chinese COMAC), but this is not the general rule. To
add to the complexity, regulators usually have subtle alignments with the manu-
facturers of their geographical areas, and some behaviours, like delegating some
supervisory activities in the supervised manufacturer (­Office of Inspector General,
2021), could be read in that context. This environment leads to frequent delays and
increases the design costs due to the requirement of more ­man-hours, including more
flight tests. The ­design-­in-development stage does not directly generate revenue (­like
research and development costs). Some of the initial orders could be cancelled owing
to delays. Even worse, the final product, if severely delayed, could be obsolete when
it is ­market-ready owing to competition with other products. Therefore, common
strategies to manage the delays are to review and streamline the design process. This
can include postponing those activities that could be attended to later and focusing
the design efforts on the more compelling tasks such as those that are more relevant
to the certification process. This streamlining process is far from easy due to the
interactions among different parts and activities of the new plane. This is the point
where a choice must be made between the logical flow of the project or the demands
of the different stakeholders. The mounting pressure can easily lead to conflicting
priorities.
In this case, one of the many changes in the design and certification planning
drove two different but related mistakes. One was not considering a key interaction,
being pulled by the urgencies of the stakeholders with competing needs and adjusting
the internal priorities to please them. The other is attached to a rushed decision and
ignoring all the inputs that could inform its inadequacy.
Maintenance, or ‘­continuous airworthiness’, as it is termed within the aviation
industry, must be planned in the early phases of the design. It is not simply a matter of
preparing the maintenance books. The design regulations impose several conditions
about accessibility or potential ­non-voluntary interactions with other systems while
maintenance is performed. Different fluid pipes, switches, and electric wiring are
subject to a scrutiny of potential unplanned interactions leading to possible damage
to the system or harm to the worker during maintenance or operations.
My job function was closely related to the design for maintenance, and the prob-
lems appeared at the beginning. Some of them can be hard to overcome, and the
‘­working in shadows’ experience is shared by manufacturers because, in the begin-
ning, the plane design is a new concept, and it does not exist yet! Hence, issues
like accessibility are analysed by using models, prototypes, and simulations with
­CAD-CAM, instead of dealing with a finished product. In addition, the organisa-
tional environment had its own issues.
First, getting the right information was not always easy since the stakeholders
were protective of their professional turf, and thus not prone to sharing information,
even though the knowledge was important to the design process. Furthermore, data
from the maintenance of planes involved in flight tests, which should be the perfect
complement to simulation data, were difficult to get because of the internal secrecy
due to cultural issues and/­or fear of possible leaks to the competitors. The lack of
disclosure about this valuable information was a significant obstacle to prototyping
and design development.
186 Ergonomic Insights

Second, the pace of design development for maintenance was slower than expected.
A crisis could arise from an announcement about delays, and there was a risk that the
manufacturer would subordinate to a schedule driven by external demands rather than
consider the significance of possible d­ esign-related issues affecting the final product.
Therefore, the new streamlining process would not be adapted to the real necessities.
Additionally, the design activity was tainted with cultural issues. Numerous meetings
were taking place, during which reaching a decision, beyond setting the date for the
next meeting, seemed impossible. Hence, progress was stalled. There was a silent
acceptance of decisions announced by senior management levels. We were discour-
aged to raise further questions or highlight more design parameters since they would
likely result in delays and, thus, were often disregarded.
That was the situation when the announcement came from the top about stopping
a major part of the design for maintenance activities and devoting its resources to
different tasks. The design process had been filled with crises, and the management
actions had been similar in all of them: decreasing budgets, decreasing workforce,
and reassigning resources. By repeating so in this case, a few major issues, like the
access to the avionics bay, would remain unsolved. Once the crisis started, the com-
munication link to raise such issues was severed since no one wanted to hear about
it. The communication channel changed shape and form, and it became lateral rather
than vertical, with the substance formed by complaints among colleagues but with-
out any escalation to the ­decision-makers. An issue could be informally raised with
a manager, who might listen and, very often, agree, but it would stop there. Nobody
dared to raise any issue that could question the quality of an announced decision,
even if that announcement seemed inadequate or ­ill-informed.
In some cases, delaying an activity was not a major issue since it had its own
certification track, for example, avionic systems. However, in some circumstances,
changes that were deemed necessary would affect parts of the design that were
closed to ongoing review. Thus, these changes were unfeasible. The power to make
the change was not held among those who saw the need. Of course, during the design
process, analysing the solutions other competitors have adopted to address an identi-
fied problem is important. For example, even in small regional planes, it is common
to have a door below the cockpit wide enough for a technician to work, and by open-
ing it, it should be designed so that a worker could keep his/­her feet on the ground
but his/­her head inside the bay.
Nevertheless, instead of having a door in this plane, the design included two holes
to accommodate the arms of technicians. Despite one of those holes being wider to
allow the technician to look inside, the access was seriously compromised. Removing
or testing any piece of the equipment inside that bay was complex, if not impossible
with the resources available to ramp engineers. That would mean that minor issues,
easily solved on the go in other models, would require more ­time – and flight ­delays –
or being postponed for them to be fixed in the hangar. In some cases, that could mean
grounding the plane until the problem was fixed.
Furthermore, should external pressures dictate ­on-time completion of tasks and
delivery of the plane for operations, engineers would probably experience severe
physical discomfort imposed by the poor design, for example, leading to the adoption
of poor body postures to achieve visibility or access to the bay. In combination with
Undertrained Workforce and Poor System Designs 187

the physical and psychological exertion of the work requirements, repetitive similar
tasks and prolonged shifts would make the perfect explosive mix of ill health and
human errors for the maintenance crew.
Once the problem of inadequate working space was detected, I tried to get the
decision reverted before closing the design by raising the issue with my boss and with
colleagues that could be affected by the design problem. Unfortunately, consistent
with the cultural norms, the issue was fully understood among peers, but no one was
willing to advise a senior ­decision-maker to review the previous decision. A cultural
environment where ‘­the boss is always right’ produces highly disciplined organisa-
tions, and the decisions coming from above are never questioned; any mention of a
potential mistake by the boss is simply unthinkable.
This single factor can explain why some cultures are excellent at getting peak per-
formance while in known territory, but they are not able to manage agile situations
where many inputs from different parts and decisions must be under constant review.
The design of a new plane cannot be a straightforward process, and dealing with it as
such can be very frustrating for many of the involved in that process.
At that moment of the process, any careful observer could appreciate that a com-
parison of the current design for a plane intended to fly in the next years with the
ones of competitors already flying would not be favourable before the eyes of future
buyers. However, omertá about wrong decisions from the top made this fact let pass
or undetected until it was impossible to fix as the design of one of the affected parts,
the fuselage, was to be considered final in a very short time. Therefore, this would
not allow late changes that, nevertheless, would not be required, should the working
space issue had been addressed.
The design of a plane is a very long process, and it can last still much longer
if delays accumulate. It is a fiercely competitive marketplace, and development is
occurring among other manufactures, which adds to the pressure of performance
and design outcomes. Time pressures can impede a proper design process. Lacking
the flexibility to make changes during the design process can mean that some identi-
fied problems remain unsolved. If this is repeated across different activities, the final
product could be obsolete at delivery or simply inadequate and unsafe to operate. In
his classic book, Porter (­1990) showed why some nations could be successful in some
markets and fail in others. The speed of decisions and room to question them in the
light of new data can be influential factors. In other cases, it can be a matter of natural
resources, but, very often, organisational culture can explain successes and failures.
Well before this design problem arose, someone familiar with the organisational
culture of the company told me ‘­When they make a plan, they can go against a wall;
they see it, they know that they will hit it, but they keep advancing until hitting the
wall. Only then, they will change the course’. My experience from this case makes
me agree with that point of view. Once they hit the wall, they will put the same
energy into the new course, and for sure, they will learn, and they will design good
products, as it happens in other markets. However, this learning process is slower
than required, and it includes avoidable and expensive mistakes.
Certainly, there were important cultural issues in this case. The negative side
of an extreme organisational discipline made it impossible to escalate major issues.
Interestingly though, there was an ‘­organisational backdoor’ that could be used by
188 Ergonomic Insights

local workers, especially if they have been working for the company for a long time.
This ‘­backdoor’ had the shape of ‘­informal meetings’ outside the office, frequently
promoted by the top. Despite its informal character, everyone was supposed to attend,
and it was a good place to know what is going on inside the company. Regretfully,
this was a resource that could be used only by insiders to raise an issue out of formal
channels. In this case, I was an outsider.
Furthermore, language problems in both directions existed. There were locals
not proficient in any language other than their own and internationals who could not
speak the local language. This was driving separation where the local group worries
were not shared with the others. In other words, the informal way was hard to open
for international staff. Therefore, even if any foreigner was present in these informal
activities, it was rather meaningless and useless, especially if, during these meetings,
there was no local manager w ­ ell-positioned and able to understand the problem from
both sides, verbally and technically.
My lesson and message from this case are that bringing external knowledge to
an organisation can be harder than expected if the organisational culture imposes
restrictions that render that knowledge useless. The working environment can look
excellent when examining routine activities, but it can kill innovation or the feasibil-
ity of raising major issues if the culture is not conducive to change.

REFERENCES
Ballesteros, J. S.-A. (­ 2007). Improving Air Safety Through Organizational Learning:
Consequences of a Technology-Led Model. CRC Press LL.
Office of Inspector General. (­2021). Weaknesses in FAA’s Certification and Delegation
Processes Hindered Its Oversight of the 737 MAX 8. Report No. AV2021020.
U.S. Department of Transportation. https://­www.oig.dot.gov/­sites/­default/­files/­
FAA%20Certification%20of%20737%20MAX%20Boeing%20II%20Final%20
Report%5E2-23-2021.pdf
Porter, M. E. (­1990). The Competitive Advantage of Nations. Macmillan.
 16 The Ergonomics
Consultants Lot Is
Not an Easy One
Rwth Stuckey
La Trobe University

Philip Meyer

CONTENTS
Working in an Adversarial Context......................................................................... 189
Regulator Actions: Enter the Ergonomists......................................................... 190
Ergonomists at 20 Paces..................................................................................... 190
Negotiation between Lawyers and Ergonomists................................................ 192
What Happened Next?....................................................................................... 193
The Outcome and Conclusions.......................................................................... 195
The Value of Evaluation.......................................................................................... 196
The Training Programme................................................................................... 197
The Evaluation................................................................................................... 198
The Outcome...................................................................................................... 199
Our Experience and Insights..............................................................................200
References............................................................................................................... 201

WORKING IN AN ADVERSARIAL CONTEXT

The setting of this case was the c­ heck-in area of a large regional airport, and the
key issues concerned the design of the workplace, the work, and the management of
workplace health and safety (­WHS). The baggage handling at the ­check-in involved
the workers undertaking three basic tasks: lifting and placing luggage brought to
them by customers on weighing scales adjacent to the counter; lifting, carrying, or
dragging each item to a conveyor at the rear of the ­check-in work area more than 2m
away; and, finally, lifting and placing each item on the conveyor in a specific ­upright-
and ­forward-facing orientation.
The hazards in the work were s­ elf-evident to the workers, with numerous injury
and incident reports of musculoskeletal disorders being the most expected conse-
quence. The work was perceived to involve actions that were repetitive, required
considerable physical force and awkward postures, and were performed in cramped
and obstructed conditions in a ­public-facing role. The worker group had more female

DOI: 10.1201/9781003349976-16 189

190 Ergonomic Insights

than male employees, and while it might be assumed that women would find the
physical work more demanding than the men, the task execution difficulties were a
common experience among all ­check-in personnel.
The ­check-in counters were provided by the employer, not the airport. At the time,
the employer was a large company with a major presence in Australian air travel.
The ­check-in counters were of a standard design and common across several airports
that the company operated. Each item of passenger luggage was notionally limited
to an absolute maximum of 32 kg weight. However, it was common in the airline
industry (­essentially for marketing reasons) that passenger bag weight limits were
poorly applied, and there were no other load factors considered including baggage
size, shape, rigidity, or grasp demands.

Regulator Actions: Enter the Ergonomists

The case was instigated by the jurisdictional WHS Regulator when they identified
concerns about the number of strains and injuries incurred by ­check-in staff manu-
ally moving luggage at this airport. The Regulator issued a provisional improvement
notice (­PIN) to the employer. This required them to undertake a risk assessment of
the manual handling (­MH) demands and implement improved work design with the
objective of reducing the risk of strains and injuries. A PIN was issued by the WHS
inspector as a step in a legal process to mitigate a situation where the Regulator
believed that an employer was contravening a legislative provision, and this contra-
vention was likely to continue.
In response to the PIN, the employer hired an ergonomics consultant with
an engineering background to provide the company with expert advice. This
­company-employed consultant ergonomist proposed a series of administrative con-
trols that were immediate, simple, and inexpensive. The employer believed that those
controls provided sufficient amelioration of the risk level and would be acceptable
to the Regulator. However, in a fiercely competitive industry, the employer aimed
for compliance at the least possible cost with only minor administrative tweaks, an
approach their consulting ergonomist stated was adequate. In turn, the Regulator
reviewed these proposed changes and declared the analysis inadequate and the miti-
gation insufficient, and the matter progressed to legal proceedings.
At this point, the Regulator’s WHS inspector, who was managing the case,
engaged us as their consultant ergonomists to obtain a second opinion. After review-
ing the inspectorate’s assessments and decisions, we chose to be involved, although
we did not usually work with legal disputes due to their adversarial nature. However,
this matter appeared to be one of a powerful organisation ‘­bullying’ the Regulator,
in a region where they were a major employer and jobs were hard to find, and we felt
that we could provide useful support to the Regulator.

Ergonomists at 20 Paces
What became immediately apparent was the different ‘­filters’ underpinning the
briefings from the two adversarial organisations to their ergonomic ‘­experts’, and the
influence of the professional backgrounds of the two different consulting ergonomists
The Ergonomics Consultants Lot Is Not an Easy One 191

on their approaches to the problem. The ergonomist engaged by the employer had an
engineering background, while the ones employed by the Regulator had a health
sciences background. The original discipline inevitably influences what any ergono-
mist understands about humans in constructed environments, including workplaces,
products, and infrastructure. The ergonomist with an engineering background had
extensive experience in WHS with a focus on the physical workplace, while we have
qualifications in ergonomics and work from a ­human-centred perspective. By using a
systems approach, we analyse workplace ergonomics and address physical and psy-
chosocial factors across all system levels.
The Regulatory authority used the National Standard and Code of Practice for
Manual Handling (­MH COP) to assess risk, which was current at the time (­NOHSC,
1990). The list of risk factors in the MH COP broadly included work and workplace
design, as well as work organisational and human factors. We visited the worksite,
observed the work over different shifts, took measurements, videoed actions, and
obtained floor plans, baggage numbers, etc., to quantify the relevant work factors. We
also spoke to workers and their managers about their perceptions of the issues and
the solutions. As per the MH COP list, it became clear that various hazards and risks
applied to much of this work.
Typical hazardous activities performed by the c­ heck-in staff and identified as work-
place hazards, according to the terminology of the MH COP, are given as follows:

• Work activities: unable to work in an upright posture; applying force across

the body, often with one hand; twisting, bending, and turning.
• Workplace layout: it forced poor postures and obstructed the pathways.
• Working postures and positions: frequent forward bending, twisting, and
sideways bending of the back.
• Weights and forces: activity duration estimated to be around one hour, gen-
erally twice per day; several hundred items handled per person and shift
of up to 32 kg weight, nominally; excessive force often applied to move a
­hard-­to-grasp object.
• Characteristics of loads and equipment: varying sizes, shapes, materials,
and weights.
• Work organisation: lack of sound work design, poor training of personnel,
unpredictable physical demands, lack of MH aids, poor control of work
times, and ­public-facing roles with high level of customer service demand.
• Work environment: obstructed pathways and some slippery tread surfaces.
• Skills and experience: uncertainty about what training had been provided in
safe MH, and staff reported limited consultation around work design.

The risk assessment was based on the presence of certain hazards coupled with our
judgement based on the e­vidence-based knowledge and experience and workers’
reports. To quantify the hazards as far as the methods at the time allowed, we carried
out a basic analysis of the postural demands using the ­then-version of the NIOSH
lifting equation1 to assess the physical demands on the body in the sagittal plane.

1 https://­www.cdc.gov/­niosh/­topics/­ergonomics/­nlecalc.html
192 Ergonomic Insights

This tool was used to provide a measure of the relative severity of those tasks that fit-
ted within its defined parameters. As often happens, the use of the tool was limited
to only part of a task being the lifting/­lowering of luggage (­suitcases, boxes, parcels,
etc.) and movement between the lifting and placing points, the scales, and the conveyor.
Therefore, other actions, such as the sustained holding, arm, trunk, and shoulder rota-
tion used to orient items on the exit conveyor, were not able to be assessed, although they
had clearly been identified as compounding the inherent risks of the work. Such limita-
tions notwithstanding, the NIOSH equation was utilised because it had been accepted
for regular use in Australian MH assessments undertaken to satisfy regulators and other
legal authorities. Although developed using a US worker population, at the time of this
case study (­late 1990s), it was universally regarded as a legitimate tool with sufficient
reliability and validity to provide useable results (­Waters et al., 1994).
The fact that much of the task activity was outside the defined tool parameters
(­as frequently happens with the application of tools in the real world) limited the
applicability of the equation. However, it was clear that the MH demands were of
an unacceptably ­high-risk level and involved regular ­one-handed and asymmetrical
loads. The use of the tool to assess those aspects of the work identified that when an
item weighed more than 16 kg in optimal circumstances, the task was judged to be at
an unacceptable level of risk. This was frequently exceeded in this workplace, where
27 kg was considered an acceptable weight in the luggage system, with bags >27 kg
tagged as a risk. Notably, this ‘­maximum’ weight was based on calculations related
to the planeload capacity, rather than job demands imposed on workers.

Negotiation between Lawyers and Ergonomists

Armed with their ergonomics experts, lawyers met to argue the case. All the
ergonomic consultants agreed that there were hazards associated with the MH of
passengers’ luggage. However, the employer’s ergonomist also agreed with the organ-
isation’s contention that less exposure in a smaller airport reduced the risk. We, the
Regulator’s ergonomists, disagreed, noting that the nature of the risk is unchanged
because the potential consequence remains irrespective of the duration of the expo-
sure, especially when the minimum cumulative load is considered. The employer
further argued that the only real data that mattered were the record of lost time
and accepted compensation claims arising from injuries suffered. This seemingly
implied that the risks do not need to be addressed until a serious claims problem
arose. This resembles an insurance and actuarial approach to risk management but
not the approach expected by WHS legislation, which requires harm minimisation
through injury risk management as practicable as possible.
Regardless, the employer’s ergonomist did not challenge the more detailed and
significant assessment of the level of risk and hazard identification provided by the
Regulators’ consultants. We presented the findings from our assessments using both
the checklist of risk factors in the MH COP and the NIOSH equation tool. These
assessments identified more than 30 elements of the ­check-in workstation and work
as inadequate and of poor design. The NIOSH risk scores for those tasks demon-
strated an urgent need for risk mitigation. These findings were accepted by both
the Regulator and the employer’s ergonomist, and it was agreed that they should
The Ergonomics Consultants Lot Is Not an Easy One 193

be the basis for intervention, regardless of the injury claim numbers. The employer
disagreed, but their objections were more a matter of form; they were unwilling to
accept responsibility due to the fear of consequences that any such admission would
unleash mandates for changes at other locations in their extensive system.
The approach suggested by the employer’s ergonomist relied on risks being
reduced if each worker used two hands and moved their feet whenever handling
luggage. This administrative control relied on worker behaviour changes but, in fact,
was rarely possible. It was difficult for operators to move their feet while reaching
across the scale to lift luggage because the scale impeded foot placement. Using two
hands was often difficult due to the types of handles commonly found (­or not) on
luggage and other containers. Moreover, the work design forced the work to be done
laterally, across the body, often with a low lift height, contingent upon the size and
nature of the item being managed on and off the scale.
The approach by the employer’s ergonomist reflected a reluctance to address the
issues by changing the work design and equipment. Instead, they opted for cheaper
and seemingly quick fixes. Indeed, this approach is not unreasonable when an organ-
isation has limited resources or when used as a ­short-term measure. However, this
was a large company with the means to potentially undertake substantial improve-
ments, particularly as these would then be applicable over time at their other airports.

What Happened Next?

The Regulator strongly opposed the administrative controls as the only form of man-
agement because our analysis had demonstrated that the work design, although typi-
cal for the specific industry, was poor, and the work was unnecessarily demanding.
From this point, the actions revolved around the legal dispute process directing the
Regulator, the ‘­adversarial’ consultants, and the employer to agree on what would
constitute acceptable risk control. We provided a comprehensive suite of options for
risk control for consideration and, ultimately, for implementation by the employer.
All proposals involved substantial improvements with a modest ­once-off investment
that could be offset by the savings associated with costs related to i­njury-related
absences and improvements to work productivity.
The basic problem with the system was that it functioned in two separated parallel
lines, one line being the ­check-in counter and the other the exit conveyor. The bag-
gage being processed was presented by the passengers to the system, then handled, and
moved at and between these two points by the workers. The control options included
mechanical aids to reduce lifting and holding, changes to work design (­e.g., passengers
lifting their luggage on and off the scales), a minor adaptation of the existing ­check-in
counters to remove the need for twisting, the introduction of a slide/­belt system between
the scale and exit conveyor, buffers to position the luggage correctly on the exit con-
veyor, improved training, and improved risk management by the employer. As such,
the proposed options were based on reconfiguring the work system within the existing
structure and equipment to achieve ­cost-effective risk management. Four options were
presented and prioritised based on cost and complexity, with option 1 the most preferred.
Option 1: Eliminate MH by the workers. This proposal positioned the passengers
at a point where they presented their baggage to the workers for ­check-in purposes and
194 Ergonomic Insights

then placed it onto the exit conveyor themselves. This virtually eliminated the MH
component from the workers’ duties and placed the onus on the public. This was not
an unreasonable proposition because the passengers had already brought the baggage
into the area for processing, and this extra task would not be repeated for each pas-
senger. This option could be realised by using the existing exit conveyor system with
minimal cost or disruption and through modifications to the existing layout as follows:

• Removal of the front counter and the feeder slides from their current
positions.
• Repositioning of the front counter sections into three or four booths, each
one positioned adjacent to the exit conveyor, with space between each booth
for public access.
• Modification to the counter sections in these booth arrangements to provide
a standard ergonomic s­et-up for the screen, keyboard, and related equip-
ment and documents with appropriate security provisions including confi-
dentiality screens.
• Realignment of the passenger queuing system so that all passengers waited
in one general queue, and the first available ­check-in point was available to
the first person in the queue.
• Positioning of the scales between the c­ heck-in point and the exit conveyor.
The passenger would proceed to the c­ heck-in point, place each item of lug-
gage onto the scales for weighing, slide the item into the adjacent holding
area once tagged, and proceed with their next item. After items are tagged
and tickets processed, the passenger slides their baggage onto the exit con-
veyor, upright and facing forward as required at present and assuming the
belt remained unchanged. To assist the passengers with this action, the sur-
face should be stainless steel or some other smooth surface or rolling system
(­e.g., a ball b­ earing-type system that would not snag wheels).
• Provision of a protective barrier on the side of the exit conveyor adjacent to
each point where the passenger presents, the conveyor being open adjacent
to the scale area so that the passengers can readily move their luggage into
the system.

Option 2: Raising the floor height and modifying the scales and exit conveyors. This
approach involved removing lifting demands from the workers to the public and reducing
related postural, reaching, and bending demands. Recommended changes are as follows:

• Addition of powered feeder slides/­conveyors between the scales and the exit
conveyors.
• Raising the height of the scale and front counter ­end-­of-­the-feeder slides to
300 mm.
• Recessing the scale point 200 mm from the front counter to improve public
access and reduce the workers’ reach demands.
• Dropping the height of the exit conveyor as much as possible by reducing
the size of the driver rollers and aligning the exit ­end-­of-­the-feeder slide to
meet the exit conveyor, thereby creating a slope to assist luggage movement.
The Ergonomics Consultants Lot Is Not an Easy One 195

• Raising the floor in the workers’ area behind the counter so that the feeder
slides are recessed, reducing any trip hazard.
• Replacing the existing powered exit conveyor with a unit at least 700 mm
width to accommodate large luggage and enable baggage turning.
• Positioning a ‘­trip’ at the exit conveyor end of the feeder slide to turn the
baggage.

Option 3: Implementation of feeder slides between the scales and the exit conveyor
with one powered roller adjacent to the scale in the feeder slide to assist movement
between the two handling points. However, implementing these without raising the
floor surface, which was proposed in option 2, would create a trip hazard for workers.

Option 4: Gravity feeder slides between the front counter and the exit conveyor. This
was the least preferred option as it still required lifting and turning of baggage by
the workers and did not significantly reduce the MH demands, including reaching,
twisting, and awkward postures.

Option 2, while not necessarily the preferred solution outlined in option 1, was agreed,
and legal orders were made instructing these work design recommendations be imple-
mented. The clear direction was that all controls should be adopted and implemented
simultaneously as one complete system because each component was interlinked with
the others. The situation would be reviewed in one month. However, unfortunately, in
the end, little was achieved in the way of improvement in this workplace.

The intervention was unsuccessful because the employer implemented only one
aspect of the recommended changes at any one time, rather than systemically, as
directed. Since the other components were not in place, the implementation of single
changes naturally failed. This slow progress appeared to be a strategy to undermine
the potential of the recommendations. Actions only happened after each Regulatory
review, when ­non-compliance was noted, and the issue returned to a hearing to seek
yet further legal directives. We repeatedly reviewed the progress (­or lack thereof) and
advised the Regulator of the failure to implement useful interventions. Throughout,
the importance of comprehensive and simultaneous implementation of all design
components as an integrated strategy and as had been directed was reiterated, but to
no avail.
Frustratingly, the employer proved to be a stubborn adversary to the legal WHS frame-
work of that time. Whereas the WHS regulations were enforceable by law, their conversion
into corrective actions was entirely at the bidding of this employer. As a large company and
an important local employer, they chose when and how to implement the improvements.
They chose which improvements were convenient to implement, and they demonstrated
that the controls were not effective when implemented individually and in isolation.

The Outcome and Conclusions

Ultimately, despite repeated breaches and legal directions, nothing substantially
changed. Finally, the company changed hands and within a year became defunct.
196 Ergonomic Insights

The fact that the legal interventions failed to motivate the employer to address work-
place hazards could be said to represent a failure by the Regulator and us, as the
consulting ergonomists. It is notable that not even the Regulator and the Court could
force this company to comply. Such was the employer’s influence nationally and
especially in this regional town where jobs were precious. The obstructive attitude
of the organisation within an adversarial legal system is the primary reason that this
case was never resolved satisfactorily. Stubborn resistance to change will frustrate
the best efforts to make improvements.
In the end, we did our best to provide accurate and honest interpretations of the
problems and the solutions at this workplace. The fact that the ergonomists involved
had somewhat differing orientations to the problems need not be a criticism. Such
diversity gives the practice of ergonomics depth but may be misinterpreted by those not
familiar with the discipline or not wanting to recognise the virtue of diversity. These
are not issues of ergonomics alone. Diversity of opinion occurs in all professions, but
in an adversarial legal system, it is often used to undermine sound and valid expertise.
While ergonomics expertise to improve workplace health and safety was not able to
tip the scales and persuade the employer to implement improvements this time, it very
often does to the benefit of workers and employers alike (­Ramos et al., 2017).
As a final point, it should be noted that modern Australian airport baggage
­check-in systems now include all the recommended elements for systems improve-
ments that we had proposed in option 1 over 20 years ago in this frustrating case,
including passengers undertaking their own baggage MH, lifting their luggage into a
fully automated movement system in which MH by ­check-in personnel is eliminated.

THE VALUE OF EVALUATION

A large, ­long-established Australian sugarcane processing company appointed a new
occupational health and safety (­OHS) manager. The company operations included
mills, cane trains, and railways. There were high levels of ongoing maintenance
due to the corrosive and abrasive nature of the sugar product and consequently con-
tinuous work to repair and maintain heavy machinery in the mills and the railway
system. The principal OHS concerns identified by the organisation were MH. The
OHS manager engaged us as ergonomics/­OHS consultants after proposing to man-
agement that while the company had successfully addressed the ‘­­low-hanging fruit’,
the persisting MH issues were complex and required a systems approach to haz-
ard identification, risk assessment, and risk control to improve work methods and
worker engagement.
Most of this workforce was male and had been employed by the company for sev-
eral years, often being the second or third generation of their family to work there.
The MH activities primarily related to mill, train, and railway maintenance and were
typically performed in a working environment of extreme heat and humidity. Most of
this maintenance work was performed during the hotter part of the year, and sun and
UV exposure was an additional problem for the railway gangers. Also, the work was
noisy, dusty, gritty, steamy, sticky, smelly, and usually heavy, undertaken repeatedly
in awkward and often dangerous positions.
The Ergonomics Consultants Lot Is Not an Easy One 197

The Training Programme

We proposed a participative approach to instil the knowledge and skills required
to address the MH problems, developing teams with representatives from all work-
force levels tasked to address risk mitigation (­Driessen et al., 2008). This program
was designed to achieve durable outcomes, with the required operational knowledge
and skills remaining within the organisation and removing the need for external
ergonomic interventions by the consultants. A ­6 -day program was developed and
implemented on four occasions at different worksites over a year.
Each program was presented at a relatively central site and attended by teams
from local mills consisting of operational and supervisory staff. All partici-
pants undertook or supervised the physical work, which was the focus of the
MH concerns. Although they were not excluded by us, the organisation decided
that senior managers would not attend the training. All participants were adults
with a range of educational backgrounds; some were tradespeople, while others
were skilled by dint of years of experience with the work, even if not formally
qualified.
Teams from each mill or railway depot brought an identified MH issue that they
wanted to be mitigated. While all the different areas did similar work, the issues
brought to the training varied. The intent was that the outcomes would be shared for
application across sites in the future. The syllabus was designed for adult learning
and integrated accepted ergonomics and OHS principles and methods [e.g., the local
Code of Practice for MH and evaluation tools such as the Snook psychometric tables,
NIOSH lifting equation, and Rapid Upper Limb Assessment (­RULA) (­Snook &
Ciriello, 1991; Waters et al., 1994; McAtamney & Corlett, 1993)], with the existing
company OHS systems (­e.g., job safety analyses and risk reporting and management
systems).
The programme introduced the participants to practical working methods for
­on-site task and environmental analysis of their identified actual workplace problems.
Each program culminated in presentations to middle and upper management by the
course participants who supported their case studies with concise, ­evidence-based,
costed arguments for work design improvements, prioritised implementation plans,
and projected revised risk assessments for each recommendation.
From the outset, it was emphasised in the program design that there was a need
to generate awareness of causative factors in the occurrence of MH hazards and
develop a more sophisticated approach to risk assessment and risk control to deal
with the causes, not the symptoms. The programme strongly avoided any sugges-
tion of ‘­learning how to lift’ as this approach focusses on changing individual
behaviours, rather than eliminating the hazards at their source. Instead, the pro-
gramme focussed on a systems approach to analysis and resolution, addressing all
the relevant human, equipment, organisational, and environmental risk factors.
The training was directed to the acquisition of practical knowledge and skills in
MH risk assessment and risk control using currently accepted risk assessment
methods. The use of ­team-based learning aimed to provide a spread of experience
and ideas for improvement as well as support those with poor literacy or computer
skills.
198 Ergonomic Insights

The Evaluation
A year after running the training, the ergonomists were contacted and advised
that the company senior management had the perception that the program had not
shown any evident outcomes. They asked for an evaluation of the training and its
application. That was a rare and valuable opportunity for external consultants who
seldom get to see what happened and why after they leave the workplace. Given
that the company wanted to address more of the MH problems using ­in-house
resources, the question that we were asked to address in the evaluation was the
degree to which this had or had not been achieved and generate recommendations
for improvements.
The evaluation was conducted o­ n-site, over five days, was highly consultative and
open, and included:

• Meetings with many of the program participants and OHS personnel.

• Meetings with recently appointed health, safety, and environment
coordinators.
• Review of outcomes for each of the projects addressed during the training
and any updated risk assessments.
• Review of any current projects being undertaken by the MH teams that had
participated in the training.

Surprisingly, the evaluation determined that in fact, there had been a great deal of
constructive activity by the newly trained teams. It identified an active and produc-
tive program of operational activity, including work redesign to address 138 identi-
fied hazards. Only 5% of the outcomes of these hazard management processes had
not been actioned. Ongoing intervention implementation was recorded for 57% of
the MH projects, and in 38% of the cases, appropriate risk mitigations were fully
implemented. Most of the MH training participants had continued to undertake some
MH ­problem-solving activities within their individual worksites, seemingly without
senior management’s knowledge or awareness, as explained below.
On the one hand, the evaluation showed that the participants and their direct man-
agers were confident that the training had met their expectations. Indeed, there had
been a beneficial and enduring transfer of skills and knowledge, mainly due to the
support and encouragement of the project by the company at an operational level.
However, on the other hand, the review identified significant gaps in resourcing and
communication systems. Other than resourcing, the most significant issue was the
demonstration of the success of the program to senior management.
At a high level, the sharing of successes was largely dependent on the documenta-
tion of the MH improvement activities. This, in turn, was dependent on the systems
put in place to support and assist documentation of progress. The significant gap that
was identified was a lack of intranet documentation, which did not allow the com-
munication of outcomes to more senior levels of management. Consequently, senior
management was ignorant of the successful ongoing and robust work design inter-
vention activities that their workers were systematically undertaking at operational
levels.
The Ergonomics Consultants Lot Is Not an Easy One 199

The identified gaps were further analysed to underpin recommendations for

improvement; the main ones are listed as follows:

• Assigned priority to the work of the MH teams regarding time allowance

for meetings, analysis and problem solving, report preparation, etc.
• Access to administrative support and computers to complete the assess-
ments and control proformas.
• Budget provision by the management at each mill or railway.
• Engagement of the company staff OHS personnel with the MH teams to
better embed the sustainability of the system.
• Recognition by management of the existence of the ‘­­in-house’ MH teams.
• Cooperation from the various internal departments at the worksites to assist
with implementing ideas for improvements.
• Demonstration of practical outcomes including documentation of who was
involved and how in the MH teams, and implementation of formal systems
for communicating and sharing interventions and outcomes, including ben-
efits and challenges.

Overall, the findings of the implementation and outcome evaluation of the success
of the training program can be summarised by the comments offered by the par-
ticipants during the programme evaluation. Most training participants reported they
remained engaged in solving MH problems via the teams, but a formalisation of the
MH team process and roles was required to give them official status. Nothing could
happen without management commitment and allocation of resources. Through a
return of investment analysis, specific MH budgets and resources had proved to be
­cost-effective at one work location and should be implemented at all work locations.
Also, the participants stated that p­ roblem-solving was occurring anyway, but the
training offered systematic methods and tools to address the issues. Nonetheless,
they acknowledged that the use of scoring methods may have legal implications and
must be used with caution; while acknowledging a serious hazard exists, the risk
may not be able to be adequately quantified. Moreover, documentation must be read-
ily integrated with procedural documents (­e.g., standard operating procedures), and
worksheets and assessment processes can be adapted locally but must be relatively
consistent across the organisation. Importantly, the total effort must be communicated
and shared across the organisation via the intranet to reduce duplication and wasted
effort. Evaluating the solutions is as important as solving the problems because dem-
onstrated successes prove the worth of the program to reduce MH injuries.

The Outcome
The consultants reported the results of the evaluation back to the company. The
evaluation was almost entirely informed by feedback and comments from the partic-
ipants and their managers. Almost all the projects being undertaken had been identi-
fied by the course participants and were being undertaken as ­self-directed activities.
The company management expressed confidence that the training had indeed met the
objectives and had resulted in a useful development of practical knowledge and skills
200 Ergonomic Insights

by their workforce. We also informed the company of the existence of shortcomings

in the integration of the training and its application, and lack of communications
between the MH teams and senior management about the progress of the implemen-
tation of the learning to workplace problems.

Our Experience and Insights

External consultants rarely can review their work and learn from how their interven-
tions have influenced an organisation and its processes and internal resources. Very
often, the handing over of a report is the last activity many of us see as the outcome
of our work. Typically, unless it is wisely built into our brief, we have little or no input
into the interpretation of our assessments or the application of our recommendations
to achieve successful outcomes. Those who engage us to address their perception
of the problem assume that the report we subsequently provide will fix things with-
out any further change. However, most interventions need ongoing assessment and
tweaking with a staged process of implementation and evaluation.
As a general principle, the value of ­post-implementation evaluation resides in the
opportunity to review what was done against what was recommended, and whether,
how, and why the aims and objectives were achieved. As consultants evaluating our
own intervention, it was vital that the review identified the good, the bad, and the ugly
and presented unbiased findings based on all the evidence that could be amassed.
This process brings significant opportunities for learnings for ergonomics practice
because it can reveal whether there has been a real or token implementation of the
recommended risk controls and highlight limitations, weaknesses, and/­or failures in
the outcome of the intervention.
Also, the evaluation can identify limitations of the intervention methods or recom-
mendations and provide the opportunity for a second look with the chance to define
and redefine the original intentions, outcomes, etc. Furthermore, the evaluation
might discover better outcomes than seemed possible at the conclusion of the origi-
nal intervention. Most importantly, evaluations provide a conclusion, whereas the
intervention only poses the question. Being able to achieve this is a satisfying point,
regardless of the nature of the findings, which consultants seldom get to experience.
The company in this case was commendable for its initial conviction of the need
for developing ­in-house knowledge and skills for the improvement of MH and for
commissioning the training programme. Importantly, they demonstrated the com-
mercial sense to follow up to make sure that the money that they had spent on the
consultants and invested in releasing staff to attend the training was justified and
productive. While it was good business sense to undertake the training in the first
place, it was just as good to make sure the money had been well spent.
As consultants, we were happy to know that our work was proven to be well
designed with demonstrable benefits addressing workplace MH problems and knowl-
edge transfer, and it was favourably regarded by the participants and the company
management. That we had met the brief to the satisfaction of all parties meant that
although ongoing engagement with the company was largely obviated, at least as far
as MH expertise was concerned, the consultants and the company parted on the best
of terms, both well pleased that a useful, professional outcome had been achieved.
The Ergonomics Consultants Lot Is Not an Easy One 201

As consultant ergonomists and professional practitioners, regardless of where and

how we are working, we are mindful of the fact that not everyone else is as convinced
of the value of ergonomics as we are. Hence, it is up to us as practitioners to demon-
strate good practice and be able to support our work by sound argument. As another
ergonomist once opined in a conversation with the authors, ergonomics is as much
an art as a science. Striking the balance between those two is the unenviable task of
the practitioner. It is our responsibility as representatives of the profession to provide
­evidence-based and practical interventions with integrity and imagination.

REFERENCES
Driessen, M. T., Anema, J. R., Proper, K. I., Bongers, P. M., & van der Beek, A. J. (­2008).
Stay@ Work: Participatory Ergonomics to prevent low back and neck pain among
workers: Design of a randomised controlled trial to evaluate the (­cost-) effectiveness.
BMC Musculoskeletal Disorders, 9(­1), 1–11. DOI: 10.1186/­1471-2474-9-145
McAtamney, L., & Corlett, E. N. (­ 1993). RULA: A survey method for the investiga-
tion of work-related upper limb disorders. Applied Ergonomics, 24(­2), 91–99. DOI:
10.1016/­0 003-6870(­93)­90080-s
National Occupational Health and Safety Commission. (­1990). National standard for manual
handling and national code of practice for manual handling. Canberra: Australian
Government Publishing Service.
Ramos, D., Arezes, P., & Afonso, P. (­2017). Analysis of the return on preventive measures
in musculoskeletal disorders through the benefit-cost ratio: a case study in a hospi-
tal. International Journal of Industrial Ergonomics, 60, 14–25. DOI: 10.1016/­ j.
ergon.2015.11.003
Snook, S. H., & Ciriello, V. M. (­1991.). The design of manual handling tasks: Revised tables
of maximum acceptable weights and forces. Ergonomics, 34 (­9), p­p. 1197–1213. DOI:
10.1080/­0 0140139108964855
Waters, T. R., Putz-Anderson, V., & Garg, A. (­1994). Applications manual for the revised
NIOSH lifting equation. U.S. Department of Health and Human Services, Centers
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 17 Tread Softly Because You
Tread on My Dreams
Reflections on a Poorly
Designed Tram D ­ river-Cab
Anjum Naweed
CQUniversity Australia

CONTENTS
The World of Tram Driving....................................................................................204
I Have a Bad Feeling about This.............................................................................205
Tackling the Problem..............................................................................................206
My Ergonomic Musings and Insights.....................................................................208
The Seat..............................................................................................................208
The Buttons........................................................................................................209
The Doors........................................................................................................... 211
Every Second Counts......................................................................................... 211
Hall of Mirrors................................................................................................... 211
The Pillars.......................................................................................................... 212
My “­Damning” Denouement.................................................................................. 212
The Presentation...................................................................................................... 213
My Reflections........................................................................................................ 214
References............................................................................................................... 216

This case is my first project involving trams and also reflects my first experiences
with the political intrigue inherent in i­ndustry-focused research. From a research
perspective, the insights storied here evidence a spectacular failure to include qual-
ity human factors and ergonomics (­HF/­E) input as a key step in good work design.
Although the research findings reflect more by way of successes than “­losses,” there
were many things I wish I could have done, and with the benefit of hindsight, would
do now, were I imbued with an ability to rewind time.
Based on anecdotal comments received since, my final report from this case
appears to have become a confidential and much s­ought-after assessment of tram
design. I expected some secrecy given the political climate. If you are one of the few
to have read the original report, then the “­untold” experiences shared here make a
good companion. What I experienced during this project left an indelible impression
on me and shaped my decisions and choices in future projects.

DOI: 10.1201/9781003349976-17 203

204 Ergonomic Insights

I was some years into a research fellowship in Australia at this point. I had gained
lots of industry experience, courtesy of leading research and being a Deputy Program
Leader of the safety and security portfolio for the Corporative Research Centre for
Rail Innovation. So, I had a few wins under my belt and shiny pips on my collar. I was
content in semiautonomous leadership but still inexperienced in the ways of industry
politics. My mind was wedded to pursuing science and blinded by its lights in ways
that did not always bring the bigger picture into focus.

THE WORLD OF TRAM DRIVING

Trams are designed to connect people to cities. They operate smoothly and predict-
ably in ­mixed-road traffic and through districts with high people densities. Those
who drive them must navigate throngs of pedestrians who can be oblivious to traffic
threats because they are not fully present in their surroundings (­e.g., wearing head-
phones) or fixated on other goals (­e.g., rushing to save time). Tram driving environ-
ments are therefore highly dynamic and challenging, but what does the driving itself
entail? “­Surely all the driver does is STOP and GO?” is a response I often hear. It is
a popular viewpoint in those who know little about this occupation, including some
who work within rail.
Trams are large, move on guided tracks, and the driver has a large field of view,
so tram driving may seem easy. In practice, this job has a great deal of complex-
ity. When operating their trams, drivers are “­plugged” into their vehicle posturally,
behaviourally, and cognitively, and watching a tram being operated is a skillful dis-
play of human and machine working together in complete accord.
Because trams have metal wheels and roll on metal tracks, tram handling is not
straightforward. Tribology of the wheel–rail contact captures this in technical terms
and relates to the adhesion, friction, and traction characteristics. If a driving rail
wheel applies a tangential force larger than the friction coefficient, the wheel will
slip. In layperson terms, this means a tram will not always pull up where you expect;
if you are travelling downhill, or if it is raining, wheel slippage may occur, leading to
overshoots of signals or stations, and at worst, derailment and collision. Hence, driv-
ers must know their tram, quite intimately you might say, and develop skills allowing
them to feel and drive confidently, reliably, and safely under any conditions.
The lever a tram is operated with is called a “­master controller.” This is the pri-
mary input that controls throttle and braking when moved in the correct direction.
The degree of precision necessary to control this lever means the driver must, in
effect, be a master controller … of the master controller. It is a bionic appendage, an
extension of the driver’s own body. It transforms them and the tram into a cybernetic-
like system, but it does not mean this system is ­error-proof. What if, for some reason,
the human at the helm does not respond to a need to apply the brakes and the lever
remains in the forward position?
Never fear, ­so-called solutions are here! Rail vehicles have systems designed
with varying degrees of sophistication to detect driver state, for example, if they
are distracted and slow to react, or unconscious and unable to react at all. These
systems try to intervene and stop the tram with emergency brake applications. As
“­­perception-action systems,” they force a response from the driver who must act
A Poorly Designed Tram Driver-Cab 205

within seconds to “­reset” the system, effectively to tell the machine all is okay,
only for the cycle to start all over again. These systems typically take the form of a
“­deadman” device or “­vigilance” system.
To be activated, a “­deadman” device needs be held in a certain position with sus-
tained force. Typically, it is integrated into a ­foot-pedal and needs to be kept down
during driving, or in the master controller itself and needs to be depressed or twisted
and held a certain way. Releasing the device will cause emergency brake activation.
It is possible, however, for this device to be “­defeated,” for example, if the human col-
lapses and their body keeps it activated.1 In comparison, a “­vigilance” system acti-
vates if there has been no input (­e.g., master controller movement, use of gong) after
a certain length of time. Sometimes, they may also activate in fixed intervals (­e.g.,
every 30 seconds). In both activation cases, the driver needs to acknowledge and reset
the system, with failure to do so resulting in emergency brake activation. “­Deadman”
devices and vigilance systems are legacy designs, meaning they have been around for
a while, drivers are familiar with them, and their design issues are well documented
(­Naweed et al. 2020; Naweed, Bowditch, Trigg, et al. 2022).
A final point is that tram drivers are not driving for the fun of it. Their companies
deliver a service, drivers receive a paycheck, and they must perform as expected.
Because trams share the same tracks, drivers must avoid running early or late to
prevent ­k nock-on impacts that will leave the whole system in chaos. Timeliness is
therefore a key performance indicator, and tram drivers always operate against a
backdrop of time pressure. In sum, tram driving is more complex than people per-
ceive, the environment and context of work means tram controls need to be intui-
tive and usable, and the cab itself needs to be a designed in a way that enables, not
impedes, the multifaceted needs of drivers.

I HAVE A BAD FEELING ABOUT THIS

I was approached by an engineering firm with a ­real-world problem; one that required
immediate attention, or so I was told. The person from the engineering firm who
called me stated that this was to be a collaboration, “­a partnership!” they announced
fervently, “­we need to study a tram, and we need you to do it.” The firm had no real
familiarity with HF/­E; it was a “­dark art” to them, and for many, still is. Because of
my positive reputation, they wanted to engage me under the premise that I would do
the research, and they would mediate with the rest of the stakeholders.
A few units of a b­ rand-new class of tram were in service, pending accredita-
tion from the local transport safety authority, and approval from the rail regulator
before the fleet could be commissioned. This tram was slick, with clean angular
lines, vibrant colours, and when it ran, you could feel the power and performance.
It sounded like a dream to all except the ones who mattered most: the tram drivers,
who were in a Kafkaesque nightmare. They were complaining about the ­driver-cab
of the tram, problems with its interface, issues with usability, and a laundry list of
other concerns. The transport safety authority became concerned by the potential for

1 The 2003 Waterfall rail disaster in NSW is an ­oft-referenced example of deadman device failure.
https://­www.onrsr.com.au/­publications/­­presentations-­historical-resources/­­waterfall-­rail-accident
206 Ergonomic Insights

any habits and behaviours formed in the tram to transfer adversely to the driving of
their other tram types. I started having a bad feeling about all this.
Their concerns were large enough to reach critical mass and force the involvement
of impartial university researchers. With so much money invested, nonaccredited
rolling stock,2 and the regulator watching closely, there was a lot at stake. The issue
needed investigation and r­ esolution - pronto. Enter stage left, my research assistant
and I, straight into the same old story: company makes product → ­end-user dislikes
product → ergonomist must fix product.
The firm only shared some of the specifics with me, enough to whet my appetite.
I started putting together an unexciting but robust study with good scope and empiri-
cally rigorous methodology. Only after we started the project did we come to realise
that there was no real HF/­E input in the product design in the first place.

TACKLING THE PROBLEM

I had only worked in “­heavy rail” previously, an expression for passenger/­freight
train services. While they seem heavy to us, trams are nowhere near the size and
mass of their brethren, earning them the categorisation “­light rail.”3 I assumed the
principles of HF/­E in heavy rail would c­ arry-over; rail was rail after all, and my
methodology featured the fundamentals but also some desirables. It was a long wish
list. In those days, getting sign offs for everything I wanted to do without resistance
seemed a rare occurrence, so you can imagine my surprise when I encountered none.
It felt like a win for me at the time. “­Gosh, this must be really serious,” I thought to
myself. In very general terms, I asked for:

• a privacy framework to collect data from tram drivers;

• focus groups with drivers;
• open consultation with broader stakeholders;
• cab walkthroughs and tram rides during ­full-service operation;
• freedom to assess risks/­issues that may be indirectly related to the problem
at hand as well as identifying the key hazards; and
• checking the effectiveness of any current control measures.

My overall approach was to ensure ­end-user engagement through a participatory

ergonomics process (­Wilson et al., 2005), where the workers have a say and actively
engage with the design of their work environment. ­Table 17.1 breaks down my list
into specific activities, all of which aimed to develop recommendations for redesign
or more informed control measures. A lot of review work was included, with infor-
mal cab rides up front. This was to understand what had gone on before they came to
me but also to gain some familiarity with the work environment.
I was also excited to apply a technique I had developed soon after completing my
PhD, one I have since used widely: the Scenario Invention Task Technique (­SITT).

2 Rolling stock is a generic industry term that denotes anything on rail wheels.
3 Trams are also known as streetcar, tramcar, trolley or trolleycar, and often referred to as “­light rail
vehicles” or “­LRVs”.
A Poorly Designed Tram Driver-Cab 207

­TABLE 17.1
Overview of the Activities
Documentation Review Focus Groups (­Scenario ­Drive-Cab Decomposition +
Invention Task Technique) Cab Observations
Review tram manufacturer HF/­E Tram driving tasks Informal cab rides
documents
Review tram m
­ ock-ups Job design (­operations, Cab walkthroughs
training, fleet rosters) • equipment
• tasks
• ­driver-machine interactions
Review company s­ afe-working Challenging work/­shifts Observe formal tram driving
policies • equipment
• tasks
• ­driver-machine interactions
Review safety management systems Review of new tram and -
guidelines from local transport other classes
safety authority
Review driver feedback Strategies and adaptations

This technique draws on principles from the Critical Decision Method (­Klein et al.
1989) and probes knowledge in ways enabling participants to simulate their activities
in the third person and encourage deep ­self-reflection. The chief point here is the
ability for people to generate challenging scenarios with the ability to conceptually
freeze and unfreeze time so the researcher can examine why their (­in)­actions or
(­in)­decisions make sense and determine what could happen when the reality changes.
It was important that the cab rides occurred after the SITT, so that I could examine
the scenarios concretely and validate them in the real(­er) world.
SITT has turned into a valuable tool because it helps people transition from ana-
lytical and creative thinking to systems thinking. I have used it to scaffold direct
methods of data collection like ­one-­to-one interviews and focus groups, and it works
especially well in the latter because participants can share their scenarios with each
another and offer validation.
It has been applied in rail driving (­e.g., Naweed et al. 2012; Rainbird & Naweed
2016), rail network control (­e.g., Naweed 2020), aviation maintenance (­e.g., Naweed &
Kingshott 2019; Naweed & Kourousis 2020), maritime tourism (­e.g., Pabel et al.
2020; Reynolds et al. 2021), and aged care (­e.g., Naweed et al. 2021).
My methodology was approved, the project signed off, and the ethics application
cleared through a ­low-risk pathway. The document review process was up first and
very onerous. I like a bit of document analysis (­see Naweed, Bowditch, Chapman,
et al. 2022) but, on this occasion, I felt inclined to review all documents carefully
and they were very dense and technical. The Work as Imagined vs Work as Done
(­Hollnagel 2016) concept comes to mind as a relevant summation of this experience.
208 Ergonomic Insights

I encountered lots of r­ ule-based rigidity on what must happen in the work and ide-
alised views of HF/­E practice in cab design. It made me wonder exactly what level of
­end-user engagement had been undertaken.
Data collection occurred over three days and I did four focus groups with 15 driv-
ers, with the cab observations too. It was no easy task to roster groups of drivers like
this, especially given that those able to drive the new tram were in the minority. It
particularly pleased me that all drivers approached to participate agreed to do so. It
was a real testament to how important this issue was for them.

MY ERGONOMIC MUSINGS AND INSIGHTS

The Seat
The driver experiences highlighted poor anthropometric variation (­ i.e., fit of
equipment/­technical environment with different body sizes and shapes) in the physi-
cal design of the seat in the cab. Comments were like “it’s too close,” “the arm is
not long enough,” “there is no adjustment whatsoever,” and “I’ve got sore shoulders
now”. Part of the issue was that the designers/­manufacturers had decided to move
the master controller from the console into an arm on the seat, turning it into what
they called Captain Kirk’s Chair4 (­­Figure 17.1). I’m sure there was a lot of ingenu-
ity involved, but this technical innovation robbed it of HF/­E diversity. The arm of
the seat could be pivoted in a downward direction at the location of the elbow in an
effort to accommodate those with bigger and longer arms (­most drivers), but this was
reported to transfer muscular strain to the shoulder.
There were other issues with the seat, but one oddity stood out. For some reason,
the relative positioning of the hand and arm used to operate the master controller
favoured the throttle. Let us assume that “­á” is the direction the tram is headed.
This meant that pushing forward accelerated the tram and pulling it back applied the
brakes (­i.e., á = acceleration; â = brakes). At first, that sounds logical, but the issue is
that, in other trams, it was the other way around (­i.e., â = acceleration; á = brakes).
The counter logic to directional mapping is that in emergency situations, it can be
easier to push forward than to pull back. It therefore created transfer conflicts with
other trams. Furthermore, because the arm of the seat could be pivoted downward,
and this was often the observed case, the driver’s hand was pronated over the master
controller. In conjunction with gravity and the weight of the human limb, the design
default was biased towards throttle application and speeding. This suggested that
apart from insufficient HF/­E input, little or no consideration was given to systems
thinking of how seemingly unrelated elements can, in fact, interact and generate
unanticipated outcomes.
To complement these subjective insights, I could also have used tools with quan-
titative measurements to better understand the physical impacts of integrating the
master controller into the seat. I am not a physical ergonomist, so ensuring respective

4 A ­pop-culture Star Trek reference to Captain James T. Kirk’s command chair in the Starship Enterprise,
which featured ­left- and r­ight-hand controls such as Red Alert, Yellow Alert, Shuttle Operation
Controls, and Intercom controls.
A Poorly Designed Tram Driver-Cab 209

F­ IGURE 17.1 Digital illustrations of the seat, ­a rm-rest buttons, “­­A-pillar” and door controls
in the tram cab.

expertise was available would have been important. Nonetheless, I did not know
enough about the nature of the issues when developing my methodology, and, in
hindsight, it may not have been feasible from a time or cost perspective, anyway.
Naturally, further ergonomic assessment to support anthropometric variation was
going to be a recommendation.

The Buttons
On the left arm of the seat were eight buttons, arranged in a pattern evoking divi-
natory geomancy (­­Figure 17.1). While their appearance conjured impressions of
foresight, from a HF/­E perspective, they violated nearly every tenet we hold sacred.
Some issues with them were as follows:

• poor discrimination in button design;

• no backlighting;
• uncomfortable button action;
210 Ergonomic Insights

• quantity and clustering of buttons; and

• button accessibility.

In one previous tram class, three buttons were placed in the arm of the seat. Integrating
a further five was thus a complete change in b­ utton-space and c­ ontrol-load mapping.
The three buttons on other trams were also in slightly different places in the new
tram. The buttons did not appear to have any rhyme or reason attached to either
colour mapping or placement. The “­Track Brake” and “­Doors Lock” buttons were
both red; why? The “­Hazard Light” and “­Sand Button” were both amber; why? The
“­Headlight Flasher” button was teal; why? The “­Gong” and the “­Horn” were both
white; fair enough, but at opposite ends to one another. Drivers said to me, “­yeah, I
know [where the buttons are], I have an idea because we do all the wrong things,”
and, “­it shouldn’t have to be like that.”
During the focus groups, I tested drivers by asking them to draw the button
arrangement from memory. Some of them stole a look at what others were doing but
that did not help them. Out of the 15 drivers, only one was able to do it successfully.
The poor discrimination in ­button-design and considerations for tactility meant that
drivers looked down each time they used them. “­They don’t have a little dot on the
track brake button,” said one driver, and “­in the [other trams] the gong is more acces-
sible than the horn,” said another. The stiffness of the buttons was also a source of
complaint, “­in this tram, I felt my thumb was paining each time I press the doors.”
A lack of backlighting made using the buttons in ­low-light conditions problematic.
Drivers could not see the button they wanted to use, so they turned the cab light on.
A great workaround, except for the luminosity flooding into the cab reflecting on the
windscreen. It completely washed away the visibility of the world outside and turned
it into a mirror. The driver workaround for their original workaround was to pulse
the light on and off whenever a button was needed. This way, loss of visibility was
momentary even it created a lingering retinal afterimage. So, not only were addi-
tional tasks needed (­looking down at buttons, switching light on/­off), but the driver’s
gaze and attention were momentarily taken away from the world outside. The idea
that light inside the cab could act as a pollutant in a task formed entirely around col-
lision avoidance was frightening and fascinating to me in equal measure.
The Sand, Track Brake, and Gong buttons are what drivers really needed easy
access to. The Sand button deploys a small quantity of this granular substance onto
the track to gain traction and prevent slippage, while the track brake slowed the tram
magnetically.5 In other trams, drivers flicked between these buttons with the index
and middle fingers to gain smooth control, but on this new tram, using buttons was
like playing a game of twister with your fingers. “­How could this happen?” I asked
myself. “­How on earth could this design have rolled out of the production line?”
Looking back now, I think this project was the first that truly shocked me, that high-
lighted why HF/­E was as important as it was. I started thinking what they would
make of our findings. “­They must have some idea of these problems?” I thought to
myself, “surely?”

5 When the magnet on the tram is activated, it is attracted to the rail and acts on it directly, thereby
decelerating the vehicle speed.
A Poorly Designed Tram Driver-Cab 211

The Doors
The new tram also changed how the passenger doors were operated. Compared
with the older trams, these changes meant that drivers easily forgot to preselect the
doors on the correct side of the tram when arriving at a terminus. This increased the
chances of the wrong doors being opened accidentally on the return journey with
similar issues on atypically located platforms. On one cab ride, my research assistant
and I witnessed the doors on the wrong side being opened. Hearing about it was one
thing but seeing it happen was something else. We did not hear about this issue lead-
ing to an incident, but the potential for it to was very real.
Drivers deemed the ability to Force Doors Close during driving an essential feature,
and used it all the time, despite company policy to use it sparingly, and judiciously.
You see, the passenger doors had laser beams which automatically responded to pas-
senger proximity, for example, by keeping doors open. Using the Force Doors Close
button bypassed the lasers. This option needed to be selected prior to station arrival,
but the button was sandwiched between the left and the right door ­pre-selection but-
tons (­­Figure 17.1). Because drivers pressed this button frequently and rapidly, incor-
rect door selection was more likely. Many of the issues started to feel interconnected.

Every Second Counts

One thing that emphasised the relevance of a systems lens for design was how little
changes to timing sequences in the new tram completely unbalanced the existing
system. Drivers said that the doors took longer to close, and this was verified through
a ­cross-comparison of timing sequences during cab rides. The difference was only a
few seconds, but in this world, every second counted. I remember one driver saying
about the door timing, “­I feel like I’m doing overtime. I’m drained. I’m generally
trying to keep time and now I’m losing time, it’s stressing me out.” In terms of prior
skills, a timing delay affected the ability for the driver to provide a quality service
that complied with the schedule, because it:

• Increased chances of losing right of way at intersections;

• Induced riskier ­decision-making due to increased delays and perceived
urgency; and
• Inhibited the driver’s propensity to open doors more than once, for example
to allow runners to board.

The connections were becoming clearer. Frequent use of the Force Doors Close but-
ton was a strategy used to mitigate stress, so if the button was being used in a time
of stress, the propensity to accidentally activate a button situated very close to it
naturally increased.

Hall of Mirrors
Good visibility of passengers was important. Driver scenarios created using the SITT
revealed that ­mirror-based scanning of head and crowd movements involved tacit
212 Ergonomic Insights

information. In other trams, a large ­rear-view mirror inside the cab with side mirrors
outside supported driver situation awareness of passenger movements. The ­rear-view
mirror was much smaller in the new tram, and the side mirrors had gone, replaced by
cameras feeding video into panel displays drivers needed to access through compli-
cated menus. “­There is only one mirror, and it is too small,” and “­there’s no mirror,
other than that one there…” were the sort of retorts I received when quizzing drivers
on their mirror situation.
For some drivers, the new r­ ear-view mirror was so unusable they omitted it from
their tasks altogether. Drivers were resistant to using cameras to divulge passenger
movements because of the time and task load involved, and because it lacked the
fidelity of a mirror image and provided “­unreliable” and “­second hand” information.
More guesswork for door open and close timing was therefore used above observing
of actual passenger dynamics. In conjunction with the Force Door Close activation,
this invariably increased the risk of slamming passengers and their belongings (­e.g.,
strollers) between doors. Admittedly, the cameras were not all bad. The increased
length of the new tram meant side mirrors may not have facilitated viewing down the
length of the tram. But when driving in wet weather, video images were blurred by
raindrops, and, during the night, light pollution from road vehicles contaminated the
picture. The concern was that cameras provided a warped and distorted representa-
tion of reality.

The Pillars
Finally, a main area of concern was an “­­A-Pillar” design of the left and right sides
of the cab. This meant drivers viewed the outside through two thick pillars that
angled towards the top in an “­A” shape. The size of these pillars created a visual
obstruction or “­blind spot” for drivers. During observations, I saw it was possible
for people to be completely concealed by the “­­A-Pillars”. What made it worse was
that a ­box-control panel has been situated between the “­­A-Pillar” on the ­left-side
(­­Figure 17.1). This rendered smaller people, like school children, all but invisible. A
poor design indeed in a country where driving occurs on the left! Drivers regularly
leaned out of their chair to look around the pillar. It amazed me that feedback from
drivers was needed to raise this as an issue. “­Surely, they would have known that
the A-pillar and placement of the box obstructed viewing?”. I cannot believe that
any HF/­E input or consultation with drivers went into this at the correct stage in
asset design.

MY “­DAMNING” DENOUEMENT
The transcription and analysis took a little longer than planned. During ­report-writing,
I paid attention to detail. The project background and methodology only rang up
seven out of 35 pages, so most of the report was the findings. I emailed my first draft
to my contact at the engineering firm and then we spoke over the phone. “­The find-
ings are pretty damning” my contact said. “­Really,” I thought to myself, waiting for
feedback on what needed to be tempered, clarified, adjusted, or explained with better
context. There was none of this. ­Proof-reading of my report or marked up comments
A Poorly Designed Tram Driver-Cab 213

would not be forthcoming. We met in person not long after. “­The findings are pretty
damning,” my contact said again, quite m ­ atter-­of-factly without meeting my gaze.
What did it mean? Well, of course, I knew what the word “­damning” meant, but
what was getting lost on me was why my findings were being described this way, out
of all the adjectives available. The word suggested extreme criticism and implied
guilt or error. It also hinted I was providing a testimonial of some kind, which could
lead to condemnation or ruin. “­It’s not a testimony” I thought, “­and no one is being
blamed.” It is a symptom of whatever is driving the design of the system. All it meant
is that HF/­E input, or ­in-depth consultation with HF/­E practitioners, had not hap-
pened. That was hardly a surprising outcome. From my perspective, the report identi-
fied what literature supported, and we were simply connecting the dots and showing
them what had been missed.
In my pursuit to document, capture, and share all problems as comprehensively
as possible, I did not appreciate the perception of others, nor the massive time and
cost implications my recommendations would have (­e.g., retrofitting). Had I seen
the bigger picture? Maybe not. Or maybe I had seen it but did not recognise it for
what it was. My contact had already sent the report to contacts at the company, and
a full stakeholder meeting was being arranged where findings would be presented. I
was told I would be the one leading the presentation and sharing the results with all
present.

THE PRESENTATION
I put together slides of all my findings. There were plenty of photos. More than half a
dozen people were in the room with me. I was sitting at the end of a rectangular table,
closest to the screen where the laptop cabling was located. It was not a comfortable
position. I had to present seated, crane my head upwards to see the slides and then
turn my gaze in a ~130° motion to the left if I wanted to see the faces around me.
At the farthest end of the table on the same side was someone who represented the
company; I believe they had played a role in the procurement or design process of
the tram. Let’s call this person Charlie? Directly opposite Charlie were two people
representing the rail regulator. Was I nervous? A little. The “­damning” comment
had stayed with me, but I was also excited. I still believed my role was to share my
findings as frankly and impartially as possible. Remember that my contact, who
sat opposite me, had said that my report had been sent to the company. Everyone’s
demeanor seemed positive. I felt comforted by this, assuming they had already read
the report.
During my presentation, I provided a background of the project before describ-
ing tram driving from a system perspective. I wanted to create common ground,
so everyone was aware of things that could influence performance. I shared infor-
mation on methodology, sample data from scenarios, and ­non-specific points about
­safety-critical tasks and the relevance of skill transference. I had 51 slides, and my
findings started on slide 17. They were organised in 11 sections and prefaced under
the heading: Pathways for Addressing Identified Issues.
I described everything I have shared with you. Their faces were inscrutable.
Till then, everyone had remained silent, and I assumed it would be like this for the
214 Ergonomic Insights

duration, like being at a conference. After covering the master controller, I moved on
to the buttons, calling up a photo along with the list of the issues. The silence from
the audience broke. “­Err, I think you’ll find…” someone said. I craned my head to the
far end. Let me tell you something, Charlie was open for business.
Charlie mounted a defence for the integrity of the button design on the basis they
had formed and consulted on this with a small reference group of drivers. They had
indicated which button options they liked, shared aspirations to have controls at their
fingertips, and I think they even created drawings of the layout (­perhaps one or more
were into geomancy?!). Charlie displayed complete conviction, arguing that they had
done the best possible job. I was quite taken aback by this revelation and the force
of Charlie’s assertions. I guess I did what any researcher would have done in my
place; I started citing research. I referred Charlie to Don Norman’s design principles,
illustrating how so many tenets of good design were “­violated” by the buttons. It
was a strong comeback. Too strong, maybe. I don’t think it turned into an argument,
although it felt that way. Then I said something in exasperation that I remember dis-
tinctly to this day. I said, “­the problem is you have consulted your drivers not only
as subject matter experts of tram driving, but as experts in HF/­E design. They are
expert at how to drive trams, not at HF/­E science.” There was silence. It looked like
a penny had dropped. The matter on the buttons was closed.
I continued, moving from one finding to the next. Charlie kept pace with me, try-
ing to explain their logic of each design. It went on like this. My memory is foggy
here, but we got to a point where the regulator stepped in. It was clear they under-
stood the implications of my findings. I do not recall getting through every finding,
but I do recall looking up at my recommendations slide. A final exchange from the
Regulator to Charlie went something like, “­these are Anjum’s findings and recom-
mendations. You need to address each of these in turn. Do that so that we are satis-
fied that the tram is safe, and we will sign it off.” That was the end of the meeting.
The presentation was over.

MY REFLECTIONS
At the time, I remember feeling attacked by Charlie, and validated (­perhaps even
protected) by the regulator. I was an ­early-career researcher, and I still stand by
my findings, but at the presentation, I expect Charlie felt every bit as attacked as
I did. The manner in which I delivered my findings was probably distressing and
accusatory, and I understand why it would have induced a defensive reaction. I am
reminded of Yeats’ final line of poetry from Aedh Wishes for the Cloths of Heaven:
“­Tread softly because you tread on my dreams.” Hindsight is a ­double-edged thing,
especially when you are the one doing all the treading. Of course, my contact had
been right, the findings were “­damning”, and I had put together my presentation too
much like my report. All the time, effort, blood and sweat pumped into making these
trams were at stake. And here I was, a young upstart researcher, trashing the inten-
tions of the many who had been involved. In hindsight, I now see it was my first real
foray into the politics; all that fieldwork, and I had not once thought to temper the
findings by considering their perspectives. My own contact had been little more than
a litmus test.
A Poorly Designed Tram Driver-Cab 215

A month after my presentation, I delivered a second one, this time to the senior
leadership team of the same tram company. It was a similar set up but a bigger
room. Many were in the audience, all representing different departments. I was
more mindful of my delivery this time, but I do not think that mattered. There was
no emotion from the audience, just an interest in what I found and what I believed
should be done. They wanted to know about the findings as plainly as possible. A
damage limitation or rather, “­damage correction” exercise that they needed to be
across.
If I could rewind time, I would put more care and consideration into how I
communicated my findings in that first presentation. To do this means acquiring
information I was not privy to and had not thought to seek. It was only at the
presentation that the existence of a reference group of tram drivers had been con-
firmed. I believe such a group was formed, but I question the degree to which they
were involved. Had they seen the seat? Had they understood the ergonomics of the
master controller? Did they know about the new sizing of the mirror? Were they
aware of the extra timing for door closure, or the changes to the ways doors were
operated? Doubtful. They would certainly have shared strident concerns about the
“­­A-Pillar” design before its unveiling. I would like to have consulted Charlie before
the meeting, too. Because of the nature of the assessment and the engineering firm
functioning as the intermediary, my perception was that I needed to keep distance.
My approach since is always to talk to the various company strata before getting
stuck in the work.
A key insight I gained from this project was that light rail is not heavy rail, and
the two modes could not be more different. In heavy rail, you are not penalised for
running early, but in light rail, being early is worse than being late. Both modes have
their challenges, but my appreciation for tram driving only grew. Trams had a unique
culture all of their own. I think the misplaced assumption that the two modes are
generalisable runs deep, and one reason heavy rail standards are used to inform light
rail standards from the t­op-down.
I still support that participatory ergonomics are the bedrock of applied HF/­E.
My proclamation that ­end-users with task expertise are not the same as practitioners
with HF/­E expertise was an important ­self-realisation. Sadly, I also think a lack of
this distinction is common in industry and one reason organisations find themselves
in a pickle. Insights from ­end-users are invaluable, but they need to go through a
­well-informed “­filter”. Separating the wheat from the chaff may be one of the roles
of HF/­E practitioners.
When writing this chapter, I investigated what changes were made to the tram,
and I discovered that the ­A-Pillar issue was taken seriously. An ­award-winning engi-
neering solution was used to “­fix it” in the form of analogue cameras outside the
tram and customisable screens on the inside where the “­­A-Pillars” were. I am happy
to have facilitated the success of others, but it was an expensive solution that may
have been easily remedied with proper HF/­E input in good work design. For better
or worse, the tram cab is seemingly evolving in the direction of the glass cockpit. I
am glad that our research was a step towards achieving system safety; it makes it all
worthwhile.
216 Ergonomic Insights

Last but not least, I gratefully acknowledge the research assistance from Ganesh
Balakrishnan, my partner in crime who experienced much of this story with me
­first-hand.

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Hollnagel, E. (­2016). The nitty-gritty of human factors. In S. Shorrock & C. Wiliams (­Eds.),
Human factors and ergonomics in practice: Improving system performance and human
well-being in the real world (­p­­p. 45–64). Boca Raton, FL: CRC Press.
Klein, G. A., Calderwood, R., & MacGregor, D. (­1989). Critical decision method for eliciting
knowledge. IEEE Transactions on Systems, Man, and Cybernetics, 19(­3), 462–472.
Naweed, A. (­ 2020). Getting mixed signals: Connotations of teamwork as performance
shaping factors in network controller and rail driver relationship dynamics. Applied
Ergonomics, 82, 102976.
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making and action tendencies in real-world aircraft maintenance engineering scenarios.
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tion and practice of aircraft maintenance in Australian General Aviation. Aerospace,
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Naweed, A., Balakrishnan, G., Bearman, C., Dorrian, J., & Dawson, D. (­2012). Scaling gen-
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Ergonomics & Human Factors 2012 (­­p. 235). Blackpool, UK: CRC Press.
Naweed, A., Bowditch, L., Chapman, J., Dorrian, J., & Balfe, N. (­2022). On good form?
Analysis of rail signal passed at danger pro formas and the extent to which they capture
systems influences following incidents. Safety Science, 151, 105726.
Naweed, A., Bowditch, L., Trigg, J., & Unsworth, C. (­2020). Out on a limb: Applying the
person-environment-occupation-performance model to examine injury-linked factors
among light rail drivers. Safety Science, 127, 104696.
Naweed, A., Bowditch, L., Trigg, J., & Unsworth, C. (­2022). Injury by design: A thematic
networks and system dynamics analysis of work-related musculoskeletal disorders in
tram drivers. Applied Ergonomics, 100, 103644.
Naweed, A., Stahlut, J., & O’Keeffe, V. (­2021). The essence of care: Versatility as an adaptive
response to challenges in the delivery of quality aged care by personal care attendants.
Human Factors, 64(­1), 109–125. DOI: 10.1177/­0 018720821101096200187208211010962.
Pabel, A., Naweed, A., Ferguson, S. A., & Reynolds, A. (­2020). Crack a smile: The causes and
consequences of emotional labour dysregulation in Australian reef tourism. Current
Issues in Tourism, 23(­13), 1598–1612.
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tionship to avoid rail disasters. Applied Mobilities, 2(­1), 50–66.
Reynolds, A. C., Pabel, A., Ferguson, S. A., & Naweed, A. (­2021). Causes and consequences
of sleep loss and fatigue: The worker perspective in the coral reef tourism industry.
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Press.
 18 Creating Conditions for
Successful ­Design-­in-Use
Lidiane Narimoto
EWI Works Inc.

CONTENTS
The Agriculture Case.............................................................................................. 218
Three Examples from Manufacturing..................................................................... 220
Lessons Learned...................................................................................................... 223
References...............................................................................................................224

Brazil is the biggest producer and exporter of sugarcane, reported supplying

50% of the world’s sugar (­USDA, 2021). Until 2007, 70% of the total production
was harvested manually (­CTC, 2012), with workers using a sharp knife in a very
­labour-intensive activity (­Alves, 2006; Vilela et al., 2015). It all changed that year,
when an environmental agreement was signed, forbidding burning prior to harvest-
ing, hence the mechanization of the process.
I started my Master’s in Production Engineering focused on Ergonomics in 2010,
when Brazil was in the middle of this transition from manual to mechanical harvest-
ing. It is estimated that the country’s mechanisation index now varies from 72% to
97%, depending on the region (­CONAB, 2021). The operation of such complex and
expensive machinery required new job roles in Brazilian fields, and my research
focused on the ergonomic analysis of the tasks. What was it like to harvest sugarcane
with an enormous machine instead of a knife?
During my master’s research, I was spending days at sugarcane crops, assessing
the work and discovering its characteristics and constraints. I analysed the operations
in the most varied and diverse situations, including tangled sugarcane stems, foggy
weather, night, and sloping grounds. Harvesting erect sugarcane in flat grounds on
a sunny day differs completely from harvesting under adverse conditions. It was
during adversity that the equipment’s limitations and design flaws became evident
to me. I also analysed the work during the ­off-season period, where the harvesting
teams work at the mill’s maintenance building for three to four months. Together,
they disassemble the machines, wash and clean all parts, make repairs, and assemble
machinery to be ready for the next season.
However, during my research, several other interesting observations emerged.
During the ­off-season period, besides the required maintenance, the teams did more!
They made design improvements to the machinery. For example, when working with
the operators inside the machine’s cabin, it was common to hear them say that the

DOI: 10.1201/9781003349976-18 217

218 Ergonomic Insights

team had changed something in the machine that produced an improvement. I was
curious about this. What also intrigued me was the fact that no ­brand-new machine
was put directly in the field to harvest. Instead, it first had to go to the maintenance
building for preparation. It was like buying a new car, not driving it immediately, and
sending it first to a mechanic. How could ­state-­of-­the-art, expensive capital equip-
ment be delivered in a state that was not ready for use?
When I finished my master’s, I felt like I had many more questions to answer.
Thus, I started my PhD aiming to address some questions revolving around a cen-
tral topic: the design of sugarcane harvesters. I wanted to analyse the design flaws
that I had seen in the field and study the improvements the operators had so proudly
boasted about for the past two years. Because the machines were originally invented
in Australia, I wondered about their operation in their place of origin. Was it the same
and, if not, why not?
Parallel to my academic research, I was a consultant in some projects that the
research laboratory, of which I was part, operated in cooperation with industries. I
divided my working time between agricultural work and industrial work. In industry,
it was common to see workers making minor modifications to improve their work
conditions to achieve productive outcomes. In the review of scientific literature, the
concept of “­design in use” is not new (­Rabardel, 1995; Folcher, 2003; Beguin, 2008;
Rabardel & Beguin, 2005). Research has showed that design evolves through time
and that users constantly modify artifacts or attribute new uses for them. What was
not clear to me was how they did that. Operationally speaking, how do workers, who
are not qualified designers, design? Therefore, I used my PhD as an opportunity to
investigate the matter in depth.

THE AGRICULTURE CASE

In Brazil, the sugarcane harvesting team is composed of the harvester operators, trac-
tor drivers, mechanical technicians, truck drivers, and the team leader/­supervisor.
Outsourcing the harvesting is not a common practice. Generally, the team works for
the sugar mills that also own all the equipment. During the harvesting season, opera-
tions are 24 × 7. Mechanical technicians are in the field to ensure minimal opera-
tional downtime with the harvesters being repaired onsite. Repairs are mostly done
in the fields and taking the machine back to the maintenance building is the last
resort. During the o­ ff-season, all machinery is transferred to the building, and the
team works as assistants to the mechanical technicians leading the maintenance plan.
During my research, I identified over 50 design modifications made by the ­on-site
mechanical teams. I classified them into three groups:

• Structural modifications: reinforcements/­ replacements of the machines’

structure in sections that would crack because of harvesting in adverse envi-
ronmental conditions.
• Functional modifications: solutions to respond to design flaws and specific
problems encountered by the teams.
• Operational modifications: solutions aimed at operational improvements.
These included innovations of the teams beyond responding to design
Conditions for Successful Design-in-Use 219

problems by adding and modifying equipment features. For example, the

teams installed additional lights at the back of the machines to be used dur-
ing the harvesting at night.

Therefore, ­design-­in-use occurred in reaction to design problems but also proactively

to improve different aspects, such as reliability, operation, productivity, safety, and
maintenance. In another example, they installed a water container that reused the
water from the air conditioning system so that operators could wash their hands
after their maintenance tasks. Such approaches proved so efficient that the engineers
and manufacturers’ representatives often visited the fields to catalogue the correc-
tions and improvements for retrospective analysis, incorporating the design ideas in
future machines. Hence, ­design-­in-use practices became part of the ongoing quality
improvement process.
When I analysed how the users designed and why their initiatives worked,
two main determinants were found, namely, collective work and formal support.
Collective work is related to the cooperation among different workers and the
combination of their expertise. On the one side, there is an operator who excels
at controlling and operating the machine in the most diverse situations. On the
other side, there is the mechanical technician who has a rich background and
experience in fixing, assembling, and disassembling various types and models
of harvesting machines throughout the years. Then, these two actors are placed
together in the field and face daily challenges. The operator notices a problem
and reports it to the technician, who is seen as an inventor of solutions. Together,
they elaborate and discuss alternatives. A process of brainstorming begins. They
suggest ideas to one another, verify their feasibility, and anticipate possible out-
comes. A solution is agreed, then implemented in one machine by the technician
and tested by the operator during harvesting. Adjustments and corrections can
be made and, if proven effective, the solution is replicated across the rest of the
machine fleet.
However, while the combination of different knowledge is crucial, is not enough.
The formal support by the organisation is necessary to allow innovation. The sector
is driven by continuous improvements, ranging from cultivating resistant and produc-
tive plant species to new planting techniques and logistics strategies. Improvements
in the harvesting processes are especially critical because they determine the quality
of raw material obtained and the production for the next seasons. Therefore, sugar
mills welcome actions that lead to increases in productivity, reductions of losses and
promote ­cost-saving ideas. Indeed, this is not a novelty in organisations operating
in capitalistic environments; however, there are different approaches to effectively
employing the concept.
The work of the harvesting team is structured in a way that allows the develop-
ment of social spaces and exchange of ideas and best practices among the workers.
Flexible structures provide for the autonomy of workers to put their ideas into prac-
tice and, finally, the means for their realisation in terms of equipment, tools, and
financial resources. In other words, the harvesting and the maintenance process are
organised in a fashion that allows workers to interact with each other and to make,
buy, develop, and test solutions.
220 Ergonomic Insights

For example, there are two top competing manufacturers of sugarcane harvest-
ers in the world. It is possible to spot their machines in the sugarcane fields by their
trademark colours of green or red. The mills prefer one manufacturer or the other
to maintain a homogeneous fleet. This allows better planning and efficiency (­e.g.,
training and skills in the operation and maintenance of one harvester type, supply
of parts). Thus, I was surprised when I saw a green component in the maintenance
building of only red machines. As the workers were frequently experiencing prob-
lems with the bearings, they were given the resources to purchase a bearing from the
other manufacturer just to compare and practice reverse engineering (­i.e., deductive
reasoning to learn how a product works).
Obviously, workers’ innovations have limits. They design with what they are
given, usually an already designed product that does not necessarily account for their
required tasks and capabilities, and with what else they have available. They must use
the materials within their proximal environment, and they literally produce brico-
lages, meaning novel constructions from diverse and unusual supplies. Nonetheless,
some problems needed a complete redesign initiative to achieve resolution. This can
only be performed by the engineering department of the equipment manufacturers.
During my research, I also contacted the two manufacturers to understand a little
about their design process and whether they had implemented participative, codesign
approaches with workers. Unfortunately, neither shared details about their processes,
rationalising that such information was sensitive and proprietary. Nevertheless, the
structural modifications emerging as necessary during operations were witnesses
that original designs did not entirely consider the task demands of the users in the
­often-harsh harvesting conditions of Brazil.

THREE EXAMPLES FROM MANUFACTURING

Contrasted with farms, industries such as manufacturing offer more controlled and
standardised settings. Throughout my years of practice as a consultant, I noticed that
workers’ bricolages in various industries are usually perceived by engineers, supervi-
sors, and management in general as failures or aberrances to prescribed work, or an
act in defiance of the rules. Organisational structures usually separate the different
functions into departments with specialised roles (­e.g., process engineers, quality
improvement and maintenance). In the manufacturing industry, this departmentali-
sation is more noticeable, and it is not expected that workers do a job falling outside
the sphere of their responsibility. However, this fragmentation of the work design
separates the technical sectors from the workers.
In Portuguese, there is a word called gambiarra, an informal term to designate an
improvisation. It usually has a funny or pejorative connotation of a contraption, or
a precarious, sloppy idea. More recently, a positive connotation has been identified,
indicating a clever way to overcome adversities (­Boufleur, 2006). At the shop floor,
it is common to hear from management that whatever solution made by workers is a
gambiarra, with a touch of disregard. Having in mind only the work as prescribed
and unaware of the work as done (­Shorrock, 2016), people with h­ igh-level managerial
roles are usually not aware of workers’ solutions and, when they become aware, there
is a tendency to see these solutions as unnecessary and even potentially dangerous.
Conditions for Successful Design-in-Use 221

To illustrate the above, below I am describing three examples from the time I was a
consultant. Two cases are from a company that produces medium density fiberboards
(­MDF panels) and one from a company producing corrugated pipes in ­high-density
polyethylene (­HDPE). My role in these cases was to conduct ergonomic assessments
and deliver reports with the necessary recommendations to the clients.
The first example is about a job that involved the supervision of a process that
occurred in large tanks containing the liquids used in the process. Because one tank
did not have an indication of its level, the worker used the following strategy: carry
and position a ladder next to the tank, climb the ladder, use a hammer to hit the tank
in different locations, listen to the sound produced, and climb down. Based on the
sound, the worker had an idea of the product’s level inside the tank.
From the workers’ perspective, it was clear they knew the solution to their prob-
lem; they simply did not have the means to implement it themselves. We have been
requesting an improvement for many years now. They say they must place a sensor,
but a float device like a ball would work; it is cheap, and it can show us if the tank
is full or not. The exact liquid level would be shown on a scale linked to the float
device by pulleys, a simple solution with significantly positive impact. Similar simple
devices of float switches are used to alert blind individuals to fill mugs of beverages
without spilling anything, especially scalding hot liquids. In this case, the device
emits an audible alarm and vibrates when liquid levels get close to the overflow
threshold inside containers.
Workers had been doing the hammer strategy for many years, and the hit marks
on that specific side of the tank were noticeable by a careful observer. For safety
reasons (­e.g., risk of falls), the superiors insisted workers should not use the ladder.
But without having a level indication, how would the workers acquire the necessary
information? Climbing the ladder to hammer the tank was their only option, and
the organisation would look the other way while they did it. This was an informally
accepted aberrance from their written work procedures. My impression was that the
workers were resigned as they had no expectations the organisation would implement
the float device. They mentioned it was stressful to work under conflicting requests
of not climbing while not having the information necessary to perform their tasks.
Upon reflection, I wondered “­What if there were an accident and the worker fell from
the ladder”? Would it be classified as an “­unsafe act,” deferring to the behaviour of
the employee, because “­the worker was not supposed to climb there”?
The second example regards a job involving the visual inspection of impregnated
paper sheets. The machine cuts the sheets and piles them at the end of the production
line, where two workers are positioned. They inspect each sheet, looking for stains,
folds, insects, dirt, print failures, etc. The rejected sheets are removed from the pile,
and the approved batch is transported to a different production line that places the
sheets on the MDF panels.
For the paper sheets to slide over the pile, it was necessary to reduce their static
electricity; otherwise, the sheets stuck together and caused paper jams. It was like
the jams inside of a copier, except that the length of industrial paper sheets ranges
from 2.5 to 5.5 m. This was achieved through the application of an electric current or
electrical discharge. The machine had two fixed bars for that purpose, but they were
not effective in eliminating the static electricity from the papers. Thus, additional
222 Ergonomic Insights

metal plates were provided by the engineering department to serve as supplemen-

tary sources of electric current. Depending on the size of the sheet produced, the
workers placed three to five additional metal plates on each side of the pile, left and
right. Because of the limited space, the metal plates’ handlers had contact with the
machine’s guardrails. Workers did not use gloves due to the nature of the work that
supposedly required only visual inspection without manual handling. Consequently,
workers were frequently subject to electrical shocks.
The solution devised by the workers involved placing rubber wrapped in tape all
around the guardrails. This was an insightful adaptation to overcome two design
problems. First, the original fixed bars that did not work properly in the first place,
and second, the exposure of the workers to not lethal, still uncomfortable levels
of electricity. When I saw the rubber wrapped in tape and asked about it, workers
responded: “­oh this is a gambiarra that we had to create ourselves, never mind.”
The organisation was aware of the situation because the workers talked to their
immediate supervisors about the issue. However, the organisation’s perspective was
that the matter was not a concern anymore because the workers had temporarily
insulated the guardrails. The workers felt unheard because the ideal solution to cor-
rect the original fixed bars was out of the question for the organisation. This solu-
tion would eliminate the need to position manually the additional metal plates and
the risk of exposure to electrical shocks and would also improve the quality of the
paper. Was there a better way to isolate the guardrails? In the field, some workers’
ideas are clever solutions that often just needed either to be recognised and accepted
or slightly improved and better developed before implementation. An appropriate
insulation of the guardrails should have been provided by the organisation. It would
be as functional as the rubber wrapped in tape, but it would make the impression that
the organisation addressed the problem correctly. What if the workers’ solution was
not adequate according to safety standards? Would the organisation seek strategies
that were compliant?
The third example is from a job involving the fabrication of special connections
of corrugated pipes. A corrugated pipe has a series of ridges and grooves running
parallel to each other on its surface. The ridges and grooves follow a pattern that is
perpendicular to and bisecting the centreline of the pipe. Corrugated pipes are made
of different materials, such as iron, steel, polyvinyl chloride, or HDPE. Corrugated
pipes are used where flexibility is an important factor other than strength and dura-
bility, such as in storm drains and culverts. Flexibility makes corrugated pipes more
useful and suitable for a wide variety of uses compared to rigid and noncorrugated
pipes.
In the company, large plastic extruder machines produce such pipes of diameters
ranging from 8 to 60 inches. The job of interest belongs to a series of customised solu-
tions based on clients’ requests, for example T
­ -joints and ­L-joints. To make the joints,
the workers must cut the pipes with an automatic or manual saw, depending on their
size, and glue the pieces together. This bonding is made using an extrusion welding
gun, which heats the plastic and extrudes it as a molten material. Like metal inert
gas welding for metals, the weld beads of plastic joint the pieces of pipes. The weld
beads are smoothed and finished while still warm with tools that knead and scrape.
Those are unique tools that are not commercialised, without technical names; both
Conditions for Successful Design-in-Use 223

the “­scraper” and the “­kneader” are made by the workers. To build the tools, they
use the extrusion welding gun to make the handle, and, at one extremity, they shape
it like a pestle of a spice crusher (­in case of the kneader) or attach the metal blade (­in
case of the scraper). They make various tools of different sizes, and the scrapers are
made with different types of blades. Workers were proud of their creations, walking
around the sector looking for every tool that they ever made to show me.
In this example, there was a positive facilitator. The same tools used to weld also
allowed workers to shape anything they needed in plastic, just like playing with mod-
elling clay or a hot glue gun. The organisation provided the blades, and the workers
made the handles. But what if there was no extrusion welding gun? Would the work-
ers have to adapt to use existing ­off-­the-shelf tools that are available for purchase?
Would the maintenance sector intervene? Or, most unlikely, would the organisation
find a supplier that could design customised tools?

LESSONS LEARNED
In the case and examples described above, I had different roles as a researcher and
consultant; still, on all occasions, I was a work analyst. My goal was to unravel the
work as done and understand the activity in the light of work constraints. When
you are in the field analysing work, it is almost impossible not to come across any
kind of workers’ bricolage, gambiarra, ­design-­in-use, or any other term of choice
like “­­work-around” in several countries. They exist even when the work is properly
designed, let alone when it is not!
Workers design with what they have and what they can find in the environment by
combining, recombining, and reorganising available materials. My learnings are that
workers’ design initiatives appear first as a response to problems and constraints that
they face daily when trying to complete their tasks. Problems can increase workload
and/­or impact productivity. This was true in the sugarcane harvesting case when
workers fixed structural and functional problems of the machines that impacted
operations or even stopped the harvesting activities.
The same was also true in the example from manufacturing when workers used
a hammer and a ladder to learn about the tank’s level and wrapped rubber to protect
themselves from exposure to electricity. The workers’ attempts to address and solve
the problems they experience may be effective or partially effective. Cases when
such strategies are only marginally effective still offer insights to work analysts into
possible paths to be pursued. I also learned that workers’ inventiveness does not stay
in the sphere of existing problems. They tend to go beyond and show highly innova-
tive skills when the right conditions are provided, such as when they can interact
with others to exchange and combine experiences and have the technical means or
resources.
In the manufacturing case of special connections of pipes, I believe it was a for-
tunate coincidence that the tool designated for welding allowed creating other tools
the workers needed. On one side, there was a problem of not having the right tools to
knead and scrape and, on the other side, there was an extrusion welding gun which
allowed them to craft anything in plastic. It might have been that the organisation did
not even know about it at senior management levels.
224 Ergonomic Insights

In the example from the sugarcane harvesting, conditions involved more than the
technical means. The teams were proactive and innovative because, out of neces-
sity, the organisation developed a favourable culture which was supportive of worker
design initiatives. Workers were given agency, space, equipment, and financial sup-
port to test their ideas, even if they were just a hypothesis. Most importantly, the
organisation tolerated some degree of experimentation and failure, which are neces-
sary preconditions for iterative designs.
Clearly, Brazilian sugar mills are an exceptional demonstration of users’ design at
its optimum. I do not suggest that organisations should do the same. However, they
must do the minimum which is to consult with their workers. This is already fore-
seen in work health and safety legislation in many countries, but consultation does
not have to be limited to health and safety. It can embed all work aspects, especially
considering that health, safety, productivity, quality, and other organisational objec-
tives interrelate and together contribute to business success.
Experienced workers know more about their work than anyone else, and it is only
logical that they must be allowed to think and act on work (­re)­design. The idea of
them testing a solution previously selected and imposed on them by others is not
enough. It is necessary to include workers during the entire process. Such an inclu-
sive approach generates effective solutions and engages those who matter most, the
people who do the work. Moreover, people tend to experience meaning in their work
when they feel they can contribute to creating something of value, especially when
they feel able to explore, connect, and create a positive impact. Organisations that
recognise the benefits of employee involvement can improve performance, produc-
tivity, safety, job morale, health profiles, socialisation, and overall workplace culture.
During my research and industry activities, my failures and frustrations were felt
when my communication fell flat. The ideas of workers and mine were not appreci-
ated, and any resolution was never formally acknowledged. More alarmingly, in those
instances, the workers had to hide their good work out of fear that its discovery or contri-
bution to something “­wrong” could reveal modified approaches not formally approved
by management. On the other hand, I felt successful mostly when I communicated the
findings to a receptive organisation that was prepared to track these changes and rec-
ognise the inventive nature of their employees through continual design improvements.

REFERENCES
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Boufleur, R. (­2006). A questão da gambiarra: formas alternativas de desenvolver artefatos e
suas relações com o design de produtos. Masters Thesis. ­FAU-USP: São Paulo.
CONAB. (­2021). Acompanhamento da safra brasileira de cana-de-açúcar. Safra 2021–2022.
Companhia Nacional de Abastecimento. Brasília, Terceiro levantamento 8(­3): 1–63.
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de-acucar/­item/­download/­39836_dace9b05e78210b93d898b3ff45f19c8
CTC. (­2012). Censo varietal e de produtividade em 2012. Centro de Tecnologia Canavieira.
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­em-2012.html
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 19 New Scientific Methods
and Old School Models
in Ergonomic System
Development
Thomas Hofmann, Deike Heßler,
Svenja Knothe, and Alicia Lampe
Hochschule Osnabrück

CONTENTS
Let’s Get Physical: The Need of Haptic Models in Ergonomic Design
Development........................................................................................................... 228
The Approach..................................................................................................... 229
Phase 1............................................................................................................... 230
Phase 2............................................................................................................... 231
Phase 3............................................................................................................... 232
Phase 4............................................................................................................... 234
Our Reflections and Next Steps......................................................................... 234
Usability of Standard Methods in Industrial Design Processes.............................. 236
Conceptual Development................................................................................... 238
Concept Development........................................................................................ 239
Implementation.................................................................................................. 241
The Aftermaths................................................................................................... 241
References............................................................................................................... 242

I, Thomas, the lead author of this chapter, studied industrial design with a focus on
ergonomic product and interface design. Since then, I have been primarily involved
in the development and design of industrial products as well as ­safety-critical human-
machine interfaces (­HMI) in the field of software development. My team and I, who
together wrote this chapter, design products for the ­business-­to-business (­B2B) mar-
ket and transfer the practical and scientific findings from product design and ergo-
nomics into teaching and research. I do this as part of my professorship at Osnabrück
University of Applied Sciences with the goal to promote the constellation of practical
development work, research, and teaching in a synergistic way.
Every day, we learn which findings from research and teaching are useful for
product development and vice versa, meaning how practical experience supports

DOI: 10.1201/9781003349976-19 227

228 Ergonomic Insights

science. We often realise that many theoretical findings, methods, and models have
only limited relevance for practice. This is what we cover in this chapter with a
focus on ergonomic and usability aspects in product design to clearly illustrate the
synergies and discrepancies between theory and practice. Where has the transfer of
ergonomic knowledge into practice worked well and where has it not?

LET’S GET PHYSICAL: THE NEED OF HAPTIC MODELS

IN ERGONOMIC DESIGN DEVELOPMENT
We were asked to design a new, compact, and extremely e­ asy-­to-maintain industrial
3D scanner for a company named GOM metrology GmbH.1 This process was to be
carried out in close cooperation with the engineering, marketing, and sales depart-
ments of the company. Although the project presented several complexities, as usual
in product development, here we wanted to focus on the ­usage-related characteristics.
These were important for us to optimise product usability. More specifically, the
scanner had to be designed very much with ergonomics in mind due to its special
proximity to the user and its high mobility. This means that special attention had to
be paid to the following aspects:

• Visible orientation (­front/­rear)

• Recognisable grip areas
• Good handling for mounting/­dismounting on tripods
• Ease of maintenance (­changing filters, lenses)
• Connectivity (­plug mounting)

We preferred a haptic and physically tangible design approach and decided to

work largely with physically experiential models, ­mock-ups, and simulations. This
approach seemed the most practical to us, even if it was unusual in the context of this
cooperation. Up to that point, due to the high importance of constructive elements,
we had worked almost exclusively in c­ omputer-aided design (­CAD) programmes and
the target versus performance comparisons were taking place in the virtual space.
Indeed, we had previous experience with physical models and their communication.
The main challenge was the lack of experience of GOM with this procedure as in
previous projects they had worked without physical models. Nonetheless, due to the
very good relationship with all parties involved during for more than 20 years of our
cooperation, it seemed a worthwhile idea to implement our knowledge from teaching
and research into this practical project.
What was going to happen? In the worst case, we would have left the project with
the realisation that the previous approach with CAD was more suitable than the new
one. Indeed, one might ask whether physical models should be built at all today
(­Greenberg et al., 2012). However, based on our experience in the field of product
design, it has become clear that a virtual representation of a product is still not fully
capable of being assessed in a comparable way to a physical artefact. However, this
virtual versus physical product debate (­Warnier & Verbruggen, 2014) will not be

1 https://­www.gom.com/­en/
Ergonomic System Development 229

presented further in the context of this chapter. Another question could be whether
we would have lost our reputation with the new approach, should the latter fail. The
answer is that we were in a ‘­safe to fail’ environment. Underpinned by its philosophy,
GOM is mostly open to new ideas and ultimately thrives on trying out new things.
Admittedly, it was and still is quite a comfortable situation to be allowed to try
something new with a project partner. We have been fortunate to deal with project
partners who accept novel approaches. Apart from the organisational appetite for
innovation, we believe that this has to do with trust in us, the design service provider,
but also perhaps with the fact that, as an institute at a university, we should and must,
by definition, always try out new approaches to generate new input. From our point
of view, this is a foundation of freedom in research and teaching, but perhaps also
a stroke of luck at our university, which actively supports this principle (­Spitz et al.,
2021).

The Approach
It was important for us to work on the correct scale from the beginning, in terms of
both the scanner’s external dimensions and its weight. After a short, basic sketch-
ing phase, we moved on to model building, which was carried out physically and in
CAD. Relatively early, it was decided that the final product should not have a very
expressive shape. This means it should simple enough with ­low-complexity geometry
and easy to describe by an external ­non-designer (­­Figure 19.1). After all, it was an
industrial product, which should follow the mantra ‘­form follows function’. Hence, it
was soon clear the product would end up being a small black box. However, this did

­FIGURE 19.1 First conceptional sketches in CAD.

230 Ergonomic Insights

not necessarily make the design any easier. The product should have a simple shell
design and be easy to maintain. At the same time, the case should also be robust and
have clear signalling functions (­e.g. Where is the front and the back? How do I open
the unit without damaging it?).

Phase 1
We started organising workshops in which both designers and ­non-designers (­e.g.
engineers, marketing experts, and senior management) could contribute to the design
of the product in a l­ow-threshold way. This means that our aim was not to find a
final form but to collect initial ideas for the design and create the design framework
from the point of view of all participants. We were convinced that workshops with
active participation would make more sense than purely theoretical question-answer
sessions.
In the first workshops, we brought with us many polystyrene foam blocks with
dimensions based on the expected technical and functional components (­power sup-
ply, light unity, inner construction parts, sockets, etc.). We used these blocks to draw
meaningful parting lines, signalling functions, edges, etc., and then work on them
with cutters and sandpaper. During the workshop, we asked participants of mixed
expertise to get together in pairs and generate ideas. They were asked to design the
foam blocks according to these ideas by using any of the available tools. More than
20 models were developed (­­Figure 19.2).
The participants initially seemed reserved to ‘­do design without being a designer’.
However, after a few moments of initial scepticism, the participants identified with
the method and were motivated to create a functionally and aesthetically interest-
ing design. The participants carved and sketched their designs with childlike joy.
Due to this exuberant mood, previously unthinkable discussions and ideas could be
now safely generated with no academic interventions. Like a ­role-playing game, the
participants sometimes took completely different positions and detached themselves
from their profession. The situation of a real ‘­serious play’ developed. Although this

­FIGURE 19.2 Basic foam ­mock-ups for the workshops.

Ergonomic System Development 231

created a huge mess of leftover materials, this approach had several highly positive
effects on the project:

• The basic ergonomics and usability of the sensor (­i.e. dimensions and mea-
surements) could be rudimentarily assessed and discussed at this early stage.
• Many variants could be sketched and discussed within a very short time
without having to work in CAD.
• The reception by all participants was very good.
• There were no problems in interpreting each model, which is a frequently
encountered challenge in discussions based on CAD models.
• The integration of ‘­­non-designers’ into the design process was inexpensive
and ‘­safe to fail’. There were no inhibitions to modify a model, sketch on it,
or criticise it.

In general, this methodology was inviting for participatory design. The motivation of
the participants was high, and an extremely constructive and open working atmosphere
was created. Equally important, several usability characteristics were already worked
out in this first phase. Admittedly, this method also worked well in this case because
the product to be designed was of a graspable size (­­Figures 19.3 and 19.4). This greatly
facilitated haptic (­i.e. touch) and functional examination of the models developed.

Phase 2
Based on the first workshop results, we continued the design process in CAD. The
development benefited from the fact that the participants had previously created mod-
els, which now could be recognised as 3D models on the computer. This was essential
because it is often difficult for ­non-designers to evaluate CAD models aesthetically
and functionally because they cannot imagine them physically. The CAD models
shown in this phase were largely based on the models created in the workshop, and
accordingly, the participants quickly recognised their own ideas. What’s more, the

­FIGURE 19.3 First cardboard models.

232 Ergonomic Insights

­FIGURE 19.4 Cardboard models including ­mock-ups of the technical package.

usual negative critiques were not forthcoming; the latter are, perhaps, a bad habit of
typical German ‘­brainstorming’, whereby one of the participants criticises the oth-
ers’ ideas rather than just letting them stand. Why exactly this typically ‘­German’
behaviour did not occur here, we can only guess. The most plausible seems to be that
all those involved have had a very constructive way of working together and knew
from the past how good the results become when little criticism is expressed about
new ideas. Therefore, the design could effectively progress further in this phase. The
gap among disciplines was eliminated because the participatory process integrated
all participants (­e.g. designers, usability experts, and constructors) into the design
process right from the beginning of the project.

Phase 3
After clarifying how the design should look in principle during the first two phases
(­how the enclosure separations should be implemented, what material the enclo-
sure should be made of, etc.), we moved to the final shaping phase. In this decisive
phase, it is crucial to be able to assess details precisely, recreate the ergonomics
as realistically as possible, and understand the product. For this purpose, realistic
­computer-generated imagery (­CGI) representations are usually used, or animations
of the final product are generated (­­Figure 19.5).
The disadvantage of this approach, particularly in the development of ­hand-held
products, is that a real evaluation of ergonomics is hardly possible because the refer-
ence to haptic reality is missing. Although it is already possible today to visualise
quite ­real-looking models on the computer, the physics that are so important for
an assessment (­weight, real dimensions, intuitive interaction, etc.) are missing. Our
experience in product design projects shows that users interpret a product in CAD
or virtual reality differently than a physical model. Especially, people who do not
Ergonomic System Development 233

­FIGURE 19.5 Collection of different design approaches for the final design phase.

constantly deal with CAD software or use other forms of visualisation (­e.g. tradi-
tional clay modelling or ­foam-based shaping) try to interpret digital forms and bring
in their own experiential knowledge. However, if you have a physical artefact in front
of you, the brain can hardly create its own reality; the artefact is perceived by the
senses exactly as it physically exists.
For this reason, we decided to use a m ­ ixed-reality approach (­MRX). This usu-
ally means combining physical and virtual content into an overall context that is
comprehensible to the viewer. This can mean mixing virtual content into a real space
through augmented reality (­AR) glasses or feeding a virtual car cockpit into virtual
reality (­VR) glasses while the viewer sits in a real car seat. In our case, however, we
decided to take a different approach because our product was of a size that allowed
to use a physical avatar enriched by a VR visualisation. The setup is explained in the
following paragraphs.
We created a black box with geometric dimensions to the final product. The
dummy, which was made of polystyrol foam (­­Figure 19.6), was fitted with weights to
achieve the desired weight of the final product.
The virtual part of the construction consisted of several interchangeable CAD
designs that were displayed in a VR headset. The viewer could change these designs
independently. The different CAD models were precisely mapped onto the cardboard
model (­i.e. virtually projected onto it) with the support of a marker integrated into
the physical model (­VR tracker). This rendered the product tangible as the user could
experience the different designs realistically. The surfaces and geometries could be
visually grasped, and the physical weight was sensed.
The method above made it possible to test and validate about 25 different variants
of the potential design within a very short time. This brought several advantages.
Compared to the creation of several real models with different characteristics, we
234 Ergonomic Insights

F­ IGURE 19.6 Concept visualisation how the VR controller was implemented to the MRX
model.

were able to save working time by quick creating variants in the workshop and at the
project partner’s premises. Also, while changing surfaces (­colours, structures, joints,
etc.) on physical models is extremely t­ ime-consuming and often not possible o­ n-site,
it could be performed quite easily through MRX technology. Much more advan-
tageous, however, was the functional accessibility of an MRX model. The models
could not only be moved and viewed but they could also be dismantled, opened, and
disassembled. Thus, not only aesthetic aspects could be validated, but also ergo-
nomic and technically functional parameters.
The acceptance of this method by the persons involved was very high, which
naturally increased the efficiency of the procedure. In the beginning, there were
slight difficulties in adapting the VR glasses and interacting with the dummy model.
However, due to the highly immersive and intuitive interaction, the procedure was
understood and followed within ­1–2 minutes of demonstration (­­Figures 19.7 and
19.8). What further increased the enthusiasm for this approach was that the com-
bination of VR visualisation and interaction with a physical avatar was completely
unknown and thus fascinated everybody. Of course, the fact that the technology
worked immediately also helped here! During this third phase, the basic design was
defined and relevant decisions about the details were made.

Phase 4
In the final development phase, we produced physical prototypes through 3D print-
ing, followed directly by the pilot series. Due to the MRX simulations carried out
in phase 3, in addition to the aesthetics and technical integration, the ergonomics
and usability could be well examined, and almost all potential weak points could
be identified and eliminated. Both the ­3D-printed prototypes (­­Figure 19.9) and the
pilot series were equipped with the technology components and assessed again for
usability. The points of discussion identified during the MRX were confirmed and
could be quickly remedied.

Our Reflections and Next Steps

Although we had previously tested the methods described in phases 2 and 3 above in
university teaching and identified them as an interesting approach to assessing design
Ergonomic System Development 235

­FIGURE 19.7 The MRX visualisation the user sees via the VR glasses.

­FIGURE 19.8 Live demo of the MRX experience.

236 Ergonomic Insights

­FIGURE 19.9 Production models with some marked details to be refined.

and usability, we had never conducted these with an industrial partner. Thus, in a way,
we took a risk as to whether the approach would bring the desired acceptance and,
above all, results. On the other hand, as stated above, GOM was a very ­open-minded
project partner with whom we had built trust over the years and who was always recep-
tive to new approaches in finding solutions. So, the initial conditions were favourable.
Basically, by using these methods we gained many important insights into practi-
cal parameters and were able to somewhat shorten the design process. However, apart
from the technical knowledge and the reduction of the processing time, other aspects
were much more valuable. We were able to involve all stakeholders of product devel-
opment in the design process within a very short time frame. Thus, engineers, mar-
keting experts, and sales agents were able to participate directly in the design process
and they had fun with it. We also experienced that those new methods for ergonomic
design could lead to a high level of identification with, and enthusiasm for, the process.
In this way, the design process was transformed from a strict, ­mono-discipline pro-
cess into an integrating task for the development. This was not achieved by a classical
­top-down approach, but through the integration of new participatory tools, which were
developed in teaching. Therefore, we learned that tools used to motivate students in
the class or laboratory can also work in the industry. We are glad that this experiment
worked very well in this case and is increasingly being used by other project partners.
We are working on further expanding our competence in the MRX field, transfer-
ring design tools to the virtual world and porting to VR the phase using model con-
struction foams. We are also expecting a few ‘­aha moments’ from our project partners
since this method is established in research and teaching but remains unknown in
industry practice. For us, it is an ideal situation to be able to try out new approaches
with students first and then use them with clients.

USABILITY OF STANDARD METHODS IN

INDUSTRIAL DESIGN PROCESSES
In many industrial applications, work processes are becoming increasingly complex
and are controlled, monitored, and analysed with the help of software. The task of
­user-centred design is to present this wealth of information for the users in a way that
allows them to quickly detect, evaluate, and act upon this information. A customised
Ergonomic System Development 237

­FIGURE 19.10 Design process based on DIN EN ISO ­9241-210 (­ISO, 2019).

interface can increase efficiency, employee satisfaction, and support error prevention
(­ISO, 2018). According to DIN ISO 9241 standard on the ergonomics of human-sys-
tem interaction (­ISO, 2019), the process for designing a ­user-centred interface consists
of four successive but distinct phases with possible iteration loops (­­Figure 19.10).

• Phase 1: This phase serves to determine the concrete framework conditions

for the project. For this purpose, all relevant user groups and stakeholders
and their relationships and goals must be identified.
• Phase 2: It involves specifying the user requirements and therefore defin-
ing the exact features of the system. This considers not only user wishes
but also the economic targets of the system, which can also influence work
processes and organisational structures.
• Phase 3: During this phase, concepts for the design ideas are derived and
developed from the analysis of the requirements. The various results should
be visualised (­e.g. m
­ ock-ups, simulations, and prototypes) and presented to
the users for evaluation to refine and concretise the design concept.
• Phase 4: The last phase, evaluation, is a recurring part of the process.
Through evaluation, information can be gathered on new requirements,
the strengths, and weaknesses of the design and the comparison with the
boundary conditions can be made. The validation can be carried out either
by the user himself or by an expert.

Depending on the complexity of the project, it can be difficult to obtain informa-

tion or to ensure communication among participants with ­user-centred design of an
238 Ergonomic Insights

interface. In our case, which is about the development of a h­ igher-level control sys-
tem for a production line in the automotive sector of a large industrial company, we
describe some of these complications and suggest possible solutions.

Conceptual Development
Our customer was a new client who had no previous experience with the develop-
ment of an ergonomic user interface. They wanted a control system that could track
and document material flows, work processes, machine settings, and similar process
parameters in their entirety. The generated data should have been collected in a data
lake to serve as a basis for further analyses and evaluations. The idea was to support
the process with the help of intelligent software and artificial intelligence (­AI), which
can often detect production errors more easily and present alternative solution steps.
The prerequisite for such an analysis platform is the holistic collection and consolida-
tion of process data.
To gain a fundamental understanding of the product and the manufacturing pro-
cess, the focus at the beginning of the project was on the newly built production line.
‘­Newly built’ in this case meant developed from scratch. Production was still in its
infancy, with the individual departments working with Microsoft Excel spreadsheets
and exchanging them using USB sticks. Therefore, as you can imagine, not all pro-
cesses were smoothly coordinated at the beginning. Repeatedly, this became appar-
ent during this project because we identified contradictions, insufficient agreements,
or even unclear responsibilities among personnel from several departments.
The plan was to design the interface according to DIN ISO 9241 (­ISO, 2018, 2019).
Often, customers bring their ideas about how the project should proceed, including
the generation of intermediate results and even the working methods and role of the
designer. An indication of such an intention on our customer’s side could be seen
during their provision of documents and information. The customer was initially
unaware that the work processes on the respective machines should form the basis for
the concept’s creation. Therefore, process diagrams and flowcharts were only handed
out gradually instead of from the start of the project.
Furthermore, the customer believed that only a ‘­makeover’ of the already exist-
ing forms for data input was sufficient, and no major research was necessary. Our
first lesson learned was that we must always keep in mind that the client might
not have the same background and knowledge regarding u­ ser-centred design as
the designer. When first cooperating with a new project partner, this can quickly
become an unpleasant trap. If the expectations differ greatly, misunderstandings
can arise, which, in turn, may lead to resentment and frustration in the collabora-
tion. Retrospectively, we realised that we had failed to explain to the customer that a
­higher-level structure could be devised and described only through a thorough under-
standing of the processes and the associated information by collecting input from the
users. Accordingly, the initial phase was quite lengthy and cost a grey hair or two on
both sides. From the beginning, it became clear that the application of the DIN ISO
9241 standard to the project would be difficult.
In addition, we had to adapt our working methods to the circumstances of the
COVID-19 pandemic. This meant creating new methods for us and changing
­
Ergonomic System Development 239

established procedures. Due to the pandemic, we could learn about the interactions
and interdependencies of processes only by using documents prepared in advance
by the customer and distilling information during online meetings. The lack of
­face-­to-face contact delayed the establishment of trustful communication because
there were only a few opportunities for small talk between the scheduled remote,
­web-based appointments. All participants were heavily consumed by their daily
business, which limited the time for joint discussion sessions.
Apart from personal contact, the observation of the actions on site can be more
enlightening than just a description, especially in the case of routine work. Everybody
who tries to describe routine work will mostly notice that several small intermedi-
ate steps are missed from such descriptions; however, it is often exactly these small
steps that could make the difference. In this context, we would like to mention an
‘­experiment’ we conduct during our teaching and research. We always ask students
in the introductory ergonomics course to think of all relevant steps for everyday
activities (­e.g. make coffee, water flowers, or shave) and design simple instruction
manuals. Indeed, it happens again and again that essential intermediate steps are not
identified. When asked why the protective cap on the razor was not removed before
shaving, the answer is usually ‘­Well, that goes without saying...’ - a typical miscon-
ception. NO, it cannot be taken for granted if you have never done this procedure
before. This is an important insight that we were able to transport from our teaching
into our practical project works.
Hence, at that point of the project, we once more realised that an o­ n-site visit to
the company could produce far more value and insights than a telephone conference.
Nonetheless, we believe that the high motivation of the employees and their willing-
ness to try out new methods could compensate for the omission of the o­ n-site visits
to a large extent. The first attempt to collect general information with the help of
questionnaires got off to a slow start because the production process was simply too
complicated and interwoven to explain in simple sentences. In contrast, switching to
interviews was a complete success.
We asked the customer to collect ideas latently. It turned out that some of the users
had already thought about the requirements for the new system in advance without
our intervention, and they had written them down. By giving the users the opportu-
nity to communicate any concerns, wishes, and individual ideas, they realised that
they could actively participate in the design and their input was crucial to the success
of the project. Consequently, the motivation of the employees to be involved in the
further phases was very positive because they recognised the benefits for them as
­end-users. Building further onto this opportunity, we reacted flexibly to the needs
of the users, which meant that any initial misunderstandings and knowledge gaps on
both sides could be eliminated.

Concept Development
Theoretically, according to the method described in DIN EN ISO 9­ 241-210 (­ISO,
2019), the definition of requirements follows the research phase. We had observed
this was feasible in fictitious or student projects where usually no unexpected exter-
nal occurrences take place. However, this strict separation and processing of the
240 Ergonomic Insights

individual phases might not be always possible in r­ eal-world conditions. In our proj-
ect, the information was collected throughout the first phase and was immediately
linked, analysed, and checked. As a result, no important information was lost, and all
findings could be related to each other. Likewise, additions could easily be included
in the research and requirements. When visualising contexts and processes from the
research phase and the interviews, the creation of flowcharts, screens, and m­ ock-ups
proved to be extremely helpful.
Moreover, the workflows on the machines were so extensive that a separate
flow diagram was created for each work area. This made it easy for users to check
whether the sequences and the relevant information were reproduced completely
and correctly. Allowed by the detailed collection of information, overlapping struc-
tures were quickly recognisable and could be easily included and visually prepared
in the conceptual design. It also became quickly clear that the production line
could not be viewed as a s­tand-alone entity. Instead, other departments such as
warehouse logistics and quality management had a considerable influence on the
way that the interface worked and was designed. However, this expansion of the
user group meant that further interviews had to be conducted, leading to a longer
and more extensive analysis phase. The challenge here was that the new interviews
could not be performed with the acquired routine because these persons had not
been involved in the first process phase and, thus, had no prior knowledge of the
interview procedure. Therefore, the new user groups had to be informed about the
procedure, which led to delays in the design process and to a greater amount of
work on our side.
Moreover, in the form of an interesting and insightful b­ y-product of the inter-
views, it became apparent that some designations and responsibilities had not been
established across departments. This communication deficit between the individual
departments had never been noticed before our cooperation. By uncovering, discuss-
ing, and eliminating these discrepancies, we were able to encourage the customer to
define a uniform nomenclature and clear distribution of tasks in the control system.
Hence, in such situations, the designer might also play the role of mediator and ini-
tiator, helping to clarify problems and disagreements in workflows and encouraging
information exchange between different departments.
Iterative consultations with users refined the structure and usability of the inter-
face. Every now and then, our customer also saw ­mock-ups of the interface and
reacted with surprise to placeholder texts such as the names of materials and proj-
ects. In our experience, this is unfortunately not an unusual case with new collabo-
rations, as the difference between a m ­ ock-up and a finished interface is not always
understood. Thus, it was our task to clarify that in this phase the structure was in the
foreground, and we would gladly consider the desired designations when this infor-
mation was available. This scenario was repeated several times. Only after some
time, everyone understood how to read the prototypes and first drafts. In this aspect,
it becomes obvious it is sometimes a great challenge for a designer to design in a
­user-centred way when the user group is technically very deep in its own processes
and more focused on details than seeing the big picture. Therefore, we had to point
out the overall concept again and again and address technical specifications later in
the ­fine-tuning work.
Ergonomic System Development 241

Implementation
The degree to which we as designers are involved in the implementation process var-
ies from project to project. In this case, the implementation of the interface concept
was to be managed by a t­ hird-party company. The communication with these devel-
opers was completely handled by our customer, which meant we were positioned
outside this loop. The programmers of the developers had access only to our concept
description and the style guide. Since we did not have access to the implementation
status, we could not know the extent to which questions were answered correctly by
the customer’s contact person. Admittedly, this situation was extremely unsatisfying
for us because it created the feeling that we had only completed half of the project.
Especially in a ­user-centred design, the phase of testing after implementation is
the exciting one. This is where we find out whether the processes and requirements
were analysed correctly, and whether the users are optimally supported in their work.
Although the customer confirmed the users were satisfied with the interface, we are
aware that there is always room for improvement. Weaknesses and misunderstandings
can only be identified with the help of extensive feedback from the user and by observ-
ing user behaviour and adapting and optimising the respective processes accordingly.

The Aftermaths
In conclusion, it was not possible for us to carry out the project in the sense of DIN
ISO 9241, which, though, served us well as a guideline. Since new fields of work kept
emerging during the project and its scope was completely misjudged by everyone
involved at the beginning, it was almost impossible to meet the customer’s request
for a rough concept after just a few weeks. This case shows once again that an atmo-
sphere of good communication is the basis for successful cooperation. Even if it
is sometimes tiresome to explain things repeatedly, it is important to maintain a
respectful and friendly communication style, even in difficult situations.
Not only the communication between contractors and clients but also ­in-house
communication can lead to tensions. The task of the designer is then to act as a
translator to clarify the misunderstandings. Especially in projects like this one, with
a large interdisciplinary team from different departments, finding a ‘­common lan-
guage’ is essential. In our case, it was not clear for a very long time who the actual
project sponsor was and what authorisations existed for this person to significantly
control and influence processes. Each department spoke about the sponsor, but when
asked, each department meant a different person! Only an interdepartmental meeting
could finally clarify who this ominous sponsor was.
Furthermore, our experience from this project showed that the various disciplines
do not only differ in the ways of communication but also their approaches to prob-
lems. Engineers like to fall back on proven and established solutions when solving
problems. We, the designers, on the other hand, consider many possibilities, even
seemingly crazy ideas, to reach the goal and only later do we check several possibili-
ties and combinations to ensure feasibility and usefulness.
Finally, it must be pointed out that, although we would have liked to accompany
the implementation, we can still look back on a successful project. The customer has
242 Ergonomic Insights

gained great confidence in our work and would like to carry out an extension of the
system with us. Thus, even where the practice deviated from the theory, we were able
to find alternative solutions and compromises together with the help of the team. We
are curious to see what will await us in the ­follow-up assignment.

REFERENCES
Greenberg, S., Carpendale, S., Marquardt, N., & Buxton, B. (­2012). Sketching User Experience,
MK Morgan Kaufmann, Elsevier, Amsterdam, The Netherlands.
ISO. (­2018). DIN EN ISO 9241-11: Ergonomics of Human-System Interaction - Part 11:
Usability: Definitions and Concepts, International Standardisation Organisation,
Geneva, Switzerland.
ISO. (­2019). DIN EN ISO 9241-210: Ergonomics of Human-System Interaction - Part
210: Human-Centred Design of Interactive Systems, International Standardisation
Organisation, Geneva, Switzerland.
Spitz, R., Böninger, C., Frenkler, F., & Schmidhuber, S. (­2021). Designing Design Education,
AV Edition, Stuttgart, Germany.
Warnier, C., & Verbruggen, D. (­2014). Dinge Drucken – Wie 3D Drucken das Design verän-
dert, Gestalten, Berlin, Germany.
20 It’s Only a
Reporting Form
Brian Thoroman
Queensland Rail

CONTENTS
Failing to Lead, Leading to Failure.........................................................................244
Learning from Failure.............................................................................................246
Moving Forward from Failure................................................................................ 247
Lessons Learned...................................................................................................... 249
Recommendations................................................................................................... 250
References............................................................................................................... 252

Before the principles of effective ­human-centred, ­user-centred, or good work design

were clearly articulated and communicated (­Safe Work Australia 2015; Horberry
et al., 2019), safety practitioners often learnt similar lessons through trial and error
while implementing various safety interventions. While this may not have been the
most efficient way to support safety in our organisations, it provided practitioners with
­on-­the-ground experiences of what worked and what didn’t in practice. Gratefully,
we now have the language to describe and discuss these approaches to safety change
management and can apply them to provide more robust and effective interventions.
The context of this case is the implementation of a new incident reporting from
within the led outdoor activity sector. The led outdoor activity sector delivers facili-
tated or instructed activities in outdoor education and recreation. Outdoor education,
in Australia, is an experience common to students from a young age. These outdoor
education programmes occur over time frames ranging from a single session to mul-
tiple weeks and include activities such as bushwalking, canoeing, rock climbing, and
cycling. Further, these programmes occur in a variety of settings, from p­ urpose-built
camps to public lands and across variable terrains ranging from urban environments
to remote outdoor locations. Environmental conditions in which outdoor educations
programmes take place can substantially affect the potential hazards encountered,
including high winds and the potential for tree or limb fall, high temperatures and the
risks of hyperthermia, and rainfalls leading to swollen rivers and flooded campsites.
In 2008, during a g­ orge-walking activity in New Zealand, f­ ast-rising water from
heavy rains created conditions in which six students and a teacher drowned (­Brookes
et al., 2009). The unpredictable and dynamic nature of outdoor education programmes
means there is tremendous uncertainty around which decisions are made; this creates
conditions in which injury and death can occur. Even in relatively contained pro-
grammes, such as ­centre-based camps at single locations, this uncertainty can lead to

DOI: 10.1201/9781003349976-20 243

244 Ergonomic Insights

fatalities, such as the drowning of a student during a dam swimming activity (­White,
2014). The complex interactions among the variability of activities, locations, condi-
tions, equipment, and people in a largely unregulated industry require that organisa-
tions delivering outdoor education must learn as much as possible from every aspect
of their work, from routine work to near misses and incidents.

FAILING TO LEAD, LEADING TO FAILURE

To paraphrase a comment attributed to Dr Kerr L. White, ‘­Good judgment comes
from experience which comes from bad judgment’ (­Farley, 2013). This has been true
in my practice, and I think applies to most organisations. While this sounds like a
­tongue-­in-cheek description of the learning process, it aligns well with some of the
concepts of organisational learning such as ­double-loop learning and modification
of d­ ecision-making or goals based on experience (­Argyris, 1977). Throughout my
career, applying human factors and ergonomics (­HFE) in the domains of risk man-
agement and safety, I have seen and experienced this process several times.
Years ago, when still a novice practitioner, ripe for bad judgment and the associ-
ated learning, I was tasked with implementing a new incident reporting form for field
use. At this point, the sector was primarily focused on addressing safety concerns
from a people, equipment, and environment perspective (­Dallat et al., 2017). The
existing internal incident reporting process was, somewhat naturally, aligned with
the prevalent approach that was considered best practice at the time in the sector.
During that period, the primary focus of the outdoor sector from a safety perspec-
tive was focussed on the development of skills, training, and experience for f­ ront-line
field staff. Incident data were captured to identify what had happened with the expec-
tation that the expertise in the field would then manage those issues locally, based on
the abilities and competencies of individuals (­Carden et al., 2017). While it is now
becoming accepted that incidents in the led outdoor activity sector are better under-
stood as system events (­Salmon et al., 2010), this was not the case at the time. The
effects of this focus on individual causal factors for incidents cascaded throughout
the safety management system of the organisation.
The extant incident reporting form had been implemented for several years and
was deeply integrated into the organisation at multiple levels. The reporting form
was a key component of f­ront-line worker training and ­in-field incident and emer-
gency management processes. Accordingly, all organisation reporting and associated
processes had been predicated on the data captured from this form for years. This
included all the supporting administration processes and information technology as
well as the management reporting processes such as quarterly and annual CEO and
board reports. Nevertheless, the edict had come down from the executive that the
organisation had committed to a new incident reporting method and documentation
form. In hindsight, this ­top-down mandate should have been a red flag for the reasons
I explain below. Back then, it was not perceived as such.
Changing a form is one thing, but shifting thinking is another. All our organisa-
tional, technological, and human systems were geared towards the previous inci-
dent form and coupled with a strong cultural belief that we, as an organisation, were
already ­sector-leading in our approaches. Hence, resistance to this change wasn’t
It’s Only a Reporting Form 245

futile, it was inevitable. I didn’t know it at the time, but there was already reticence
across the teams with a sense of distrust with the new incident reporting form com-
ing from an external research group. In my blissful ignorance, I simply ploughed
forward.
The word from the executive was to ‘­just get it out there’ because ‘­it’s only a
reporting form’. Therefore, I began putting the new form into the hands of f­ ront-line
operational staff. They were given no training and no communication or consul-
tation, and none of the administrative staff was informed of the change. I believe
you can guess what the response was: loud and consistent refusal, grumblings from
­front-line staff, loss of safety data, complaints the new form was considered overly
onerous and inapplicable to the types of incidents found in the sector, and on and on.
Reflecting now on the rollout of the new safety intervention, and with the benefit
of hindsight, I can identify what went well and what went poorly from this initial
attempt. What went well is that the project had executive leadership support, a key
component that is often missing from safety initiatives and is critical to implement-
ing organisational change (­Cameron & Green, 2019). Another component that went
well was the intent of the incident form itself.
The incident form had been developed by safety science academic researchers and
was consistent with the modern systems thinking approach to safety. It was designed
to capture contributory factors across the ­socio-technical system rather than those
only at the ­so-called sharp end of work. This was done using a contributory factors
framework to identify the impacts of decisions and actions from not just ­front-line
workers but also those arising from the ‘­blunt end’, including company management,
regulators, and government. This exact intent of the project to improve safety for our
organisation and our sector was one of the drivers of the adoption of the incident
form.
However, while ­front-line workers appreciated the intent of the initiative to
improve safety, the implementation of an effective approach to safety change man-
agement was sorely lacking. The bad news was that few, if any, of the principles
of good work design (­GWD; Karanikas et al., 2021) were applied (­­Table 20.1).
Furthermore, the principles of ­human-centred (­or u­ ser-centred) design (­HCD; ISO
­9241-210:2010) were also not considered, such as the design being driven and refined
through ­user-centred evaluation or the design team including multidisciplinary skills
and perspectives. Due to this lack of application of the principles of GWD, the initial
attempt to deliver a modern incident analysis form to the ­front-line staff resulted in
a complete failure.
Overall, the cultural conflict between how work was done and the vision for work
in future was not identified at the time. Now, with the benefit of further education
and experience, I have a better understanding of the ­so-called research and prac-
tice gap (­Chung & Shorrock, 2011). At the time, I had no idea that such a concept
existed, and I certainly did not understand how to address it to implement a modern
­HFE-informed safety intervention or apply effective principles of change manage-
ment (­Mento et al., 2002).
Following on from the failure of the initial rollout attempt, I had an opportunity to
highlight the challenges of delivering such a ­top-down design approach and explain
how the failure of the rollout was a s­ ystem-wide issue that required a s­ ystem-wide
246 Ergonomic Insights

­ ABLE 20.1
T
Evaluation of Initial Incident Form Rollout against Principles of Good Work
Design (­GWD; Karanikas et al. (­2021) and ­Human-Centred Design (­HCD;
ISO ­9241-210:2010)).
Analysis of application in this case
Component of GWD Principles of HCD (­failed phase)
­Discovery – engage Users are involved No ­end-user engagement.
people throughout design and
development
­Discovery – study The design is based upon Context, tasks, work, and jobs were known and
context, tasks, work, an explicit analysed; however, this information was not
and jobs understanding of user, included in the rollout strategy.
tasks, and environment
­Design – develop The design addresses the The incident form was delivered by a third party;
concepts whole user experience no changes were allowed in the initial rollout. No
­Design – trial iterative The process is iterative ­end-user engagement in design.
prototypes
­Design – determine The consequences of the new incident form were
acceptable ­trade-Offs not analysed. No goal conflicts, ­trade-offs, or
variability were considered.
­Realisation – business The design team includes No integration with other business areas.
areas integration multidisciplinary skills Information technology, training, and product
and perspectives delivery were not engaged in the initial rollout
plan.
­Realisation – No consultation prior to implementation
consultation and
implementation
­Realisation – evaluation The design is driven and No planned evaluation or monitoring.
and monitoring refined by u­ ser-centred
evaluation

solution. The loss of incident data and negative ­end-user feedback from every pro-
gramme under the rollout was a clear indication that something had gone drastically
wrong. Gratefully, the failure had been so significant, that there was executive leader-
ship support to try another approach.

LEARNING FROM FAILURE

Our initial activity was to unpack all the ways in which the first attempt had failed,
using a small learning teams’ approach to understand stakeholder impact. Team
members included (­1) f­ront-line operational staff, (­2) the information technology
teams who would need to be engaged with implementing the changes to the data-
base, (­3) the administrative staff who would be entering data into the system, (­4)
the researchers who had developed the original draft, and (­5) the executive who
It’s Only a Reporting Form 247

would need to allocate resources to support the project. They were all brought in and
encouraged to describe the potential impacts of the safety change from their point of
view. From the perspective of GWD, we had begun the iterative process of engaging
stakeholders to learn the shortcomings of the initial rollout.
Reassessing stakeholder engagement provided insights for the second phase of the
discovery process to understand the context and breadth of the changes we were trying
to implement. We realised that we had underestimated the impact of this project on all
aspects of the organisation and would need to consider integration, implementation, and
evaluation to better understand how stakeholders were impacted by this seemingly small
change. All our incident trends and management reporting to internal stakeholders and
board members were predicated on the existing form. Similarly, all safety interventions,
trend analysis, and training systems that we used as part of our customer value proposi-
tion were based on the data that had been previously collected. Expectedly, there were
widespread concerns that all that learning would be lost during the transition. Thus, our
‘­one simple change’ created issues at almost every level of our system.
Analysis from that first rollout taught us several important lessons in relation to
our incident form design and implementation. First, incident form design has a large
effect on the quality, amount, and type of information captured. Second, good inci-
dent form design requires engagement with the first order ­front-line operational staff
who will be using it as well as the second and t­hird-order e­ nd-users who perform
supporting tasks. Third, any design process must be iterative with rounds of piloting,
feedback, and refinement. Finally, we realised that implementation requires a signifi-
cant allocation of resources and commitment to collaboration across the levels of the
organisation to ensure the success of the project.

MOVING FORWARD FROM FAILURE

Once we had begun to better understand the problem, we were able to take a much
more ­user-centred approach to the design of the form. By considering the purposes
of the form from both research and practice perspectives, user tasks and workload,
including time pressures, as well as broader organisational requirements, we were
able to come up with a draft form that would fulfil the needs of all our stakeholders.
This draft was then reviewed by ­front-end users and modified to create a version that
met the needs as we understood them and was usable. This process of structured
­end-user engagement created momentum and interest from our main user group in
support of our ­in-field design trials.
We ran a series of short, iterative design pilots where we used a draft for a week or
two with a select group, got feedback and then refined and ­re-trialled the form. Each
iteration was reviewed by the e­ nd-users and the development team to ensure that
changes did not negatively impact or misconstrue the key purposes of the form. Over
time, the form became continually refined until a workable product had been pro-
duced. As this design phase was occurring over the course of several months, there
was simultaneous engagement with the onset of the ongoing realisation process.
Due to the higher speed of the iterative design phase and the delay associated with
large system changes, the process and timing of the ­back-end changes also had to be
considered. Additional challenges included the additional complexity of providing
248 Ergonomic Insights

data to the research group that had developed the original new incident reporting
form while satisfying organisational reporting needs. In the end, it was determined to
initially run the two systems, legacy and updated, in parallel until the updated system
provided all the necessary functionality to replace the legacy system. To facilitate
this transition to the realisation phase, ­back-end process teams were engaged.
In the early parts of the design phase, we began to communicate with ­back-end
process teams (­e.g. information technology, training, staffing, and administration)
to understand operational requirements and build design briefs for necessary system
changes (­see ­Table 20.2 for a summary of project impacts across teams). Because these
larger system changes take quite a lot of time and resources, it was crucial to involve
these teams early in the process. This way they could understand the scope of the
change requirements and do preliminary work and plan for future resourcing needs.
The initial parallel systems implementation phase was supported by the form
design process itself. One of the updated design criteria from the discovery phase
was to continue to capture the key organisational reporting data as well as the addi-
tional data in support of the research group. During this transitional phase, additional
staffing resources were required to manually enter data into both systems. While this
was the most expensive in terms of resource allocation, it provided the smoothest
transition and ensured no loss of valuable safety data.
While the ­back-end technology and administrative processes were being devel-
oped, broader organisational processes and staff training were also being integrated.
The process of integrating all business areas required several changes to the safety
management system. Reviewing, consulting, and updating changes to the relevant
policies and procedures required yet another cycle of discovery, design, and realisa-
tion across the organisation. Similarly, working with training and development to
integrate the new form and approach into the staff training required its own cycle of

­ ABLE 20.2
T
Summary of the Project Impacts
Team Summary of safety change impact
Information • Design and develop new database architecture
Technology • Design and develop new user interface
• Transfer existing data in new system
Training • Update and deliver new incident training module
• Create new training qualification to track staff skill rollout
• Manage staff qualification updates
Staffing • Allocate or source human resources for data entry
• Train human resources for translating new incident form into legacy system
during parallel running
Administration • Update safety management system
• Provide assurance activities for data collection and data entry
• Update and communicate changes to reporting
• Provide assurance activities and analysis between legacy and updated systems
during parallel running
It’s Only a Reporting Form 249

­ ABLE 20.3
T
Actions Taken after the Failed Initial Rollout to Apply Principles of Good
Work Design (­GWD; Karanikas at al., 2021)
Component of GWD Analysis of application in this case (­successful phase)
­Discovery – engage people Multiple interviews and observations to better understand the impacts of
the change on the f­ ront-line workers.
­Discovery – study context, Analysis of the work context and tasks competing for f­ ront-line worker
tasks, work, and jobs resources that impacted the ability to use the incident form.
­Design – develop concepts ­End-user feedback and participatory design to develop incident form
concepts.
­Design – trial iterative Short t­wo-week trials with iterative design changes done with a core team
prototypes of ­front-line workers acting as change champions.
­Design – determine Prototypes were evaluated on the extent to which they met the dual
acceptable ­trade-Offs purposes of organisational reporting and research partner requirements.
­Realisation – business areas Training teams were involved in the development. Integration with
integration information technology led to the additional requirement to run dual
systems, and executive team allocated additional administrative
resources to support s­ hort-term interim solution.
­Realisation – consultation Broad consultation across organisation led to a phased implementation
and implementation approach while internal information technology systems changes could
be scoped and developed.
­Realisation – evaluation and Regular evaluation meetings on progress of design project and monitoring
monitoring of ongoing data collection both for organisational systems and research
partners.

the GWD process. ­Table 20.3 provides a summary of how we applied GWD prin-
ciples across the organisation during the safety change process.
While it took nearly a year to get there, in the end, we were able to achieve the
requirement to implement the new incident reporting form successfully and roll it out
to the organisation. Soon after completing this process, I moved on to my next profes-
sional challenge at another organisation. Fortunately, in the organisation mentioned in
this case, the implementation process continued with ongoing integration and improve-
ment. Moreover, I am happy to report that continual innovation became an integrated
process for its incident reporting. This included implementing digital incident reporting
and integration with the national incident database for the sector. By implementing the
fundamental principles of safety change management coupled with GWD and HCD,
the organisation was able to position itself for success then and in future.

LESSONS LEARNED
One of the key lessons during this safety change management process was that the
application of effective design principles requires an understanding and engagement
of the impacted system. A single safety intervention will often thread throughout
every aspect of an organisational or management system. I have found that safety
250 Ergonomic Insights

change management and work design require an understanding based on a systems

thinking approach to be successful.
A second key lesson for me was that applying the principles of effective design
is itself an iterative process, and design never really ends. Rather than applying the
principles to just ‘­the project’, we found ourselves applying them, or a subset of them,
at every stage. Discovery and realisation were critical approaches that were adopted
during the learning process from our original failure. As we discovered the mag-
nitude of the impact of the safety change, each user group went through the design
phases, which were tailored to their needs. From IT to training, an iterative cycle of
discovery, design, and realisation was required to accomplish the ­sub-tasks for the
success of the overall project goal.
Each stage within the larger safety change management project is an opportu-
nity to apply the effective design principles of discovery and engagement, iterative
design, and integrated implementation and realisation. It has been stated that the
strongest leverage points for system change are to modify or transcend our underpin-
ning paradigms from which our work systems arise (­Meadows, 2008). Thought from
this viewpoint, the design principles may support a new way of thinking about safety
change management and, therefore, become an embedded part of the organisations’
actions towards safety improvement.

RECOMMENDATIONS
At the time of this case study, neither I, the organisation, nor the sector were aware
of the tools available from the HFE discipline to support the design and implementa-
tion of safety interventions. I now understand that when a new safety intervention is
considered, it is useful to take a structured systems thinking approach that aligns with
effective design principles and applies appropriate HFE methods. This includes under-
standing the problem, context, stakeholders impacted, and the effects of the proposed
safety intervention on the system. It is crucial that the principles of effective design are
applied practically using suitable methods throughout the safety intervention lifecycle.
Meadows (­2008) cautions us to make sure that we do not find ourselves pushing
very hard in the wrong direction when intervening in systems. Therefore, it is critical to
be thorough in our understanding of what we are trying to accomplish and understand
the ‘­why’ of any safety intervention. In the initial incident form rollout case, there was
no clear purpose understood by the various stakeholders. In the subsequent application
of the process, this identification of the ‘­why’ of the safety intervention was accom-
plished by taking a step back to understand the purpose, followed by an analysis of the
probable interactions arising from the new intervention across the work system.
Applying effective design principles at the scoping stage through engaging stake-
holders and understanding the proposed work context can minimise issues later in
the design and implementation processes. This initial process, which Norman (­2013)
describes as the beginning part of the s­ o-called double diamond design process (­i.e.
first ‘­design’ the problem, then design the solution) can identify whether the correct
or ‘­real’ problem is being addressed by the proposed intervention. Further, this pro-
cess collects insights from stakeholders across the system which provides data that
can be analysed with any HFE method in the discovery and iterative design phases.
It’s Only a Reporting Form 251

The insights from the scoping and project discovery phase inform the iterative
design phase. Applying robust HFE analysis methods, or subsets of these methods,
as appropriate, such as Cognitive Work Analysis (­CWA) (­Rasmussen et al., 1994) or
the Event Analysis of Systemic Teamwork (­EAST) (­Stanton et al., 2008) can be used
to better understand the systemic influences on the proposed intervention as well as
model the impacts of the proposed intervention across the work system. Such tools
can further be used to simulate the effects of various design options. In turn, the
artefacts created from these methods in the discovery and design phases can be used
to support and inform the realisation phase.
System analysis methods applied during design provides useful insights into the
realisation phase. For example, if the EAST method (­Stanton et al., 2008) was used
during the discovery and design phases, the task and social networks created during
those phases could provide insights into the key stakeholders required for successful
delivery during the realisation phase. Had CWA (­Rasmussen et al., 1994) been used
during the discovery and design phases, the results of the Social Organisation and
Cooperation Analysis (­Vicente, 1999) could provide this information. Regardless of
the choice of specific methods, fi
­ t-­for-purpose methods application provide the ‘­how’
to practically apply the ‘­what’ of principles of effective design. In my experience,
the use of systems ­thinking-based HFE theory and methods, aligned with effec-
tive design principles, driven by a real business need, provides the best results when
implementing safety interventions (­­Figure 20.1).

F­ IGURE 20.1 The relationship among business needs, design principles, and human factors
and ergonomics methods.
252 Ergonomic Insights

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in both theory and practice. Journal of Change Management, 3(­1), 45–59.
doi:10.1080/­714042520
Norman, D. (­2013). The design of everyday things: Revised and expanded edition. Basic
Books. New York, NY.
Rasmussen, J., Pejtersen, A. M., & Goodstein, L. P. (­1994). Cognitive systems engineering.
Wiley. New York, NY.
Safe Work Australia. (­2015). Principles of good work design handbook. Safe Work Australia.
Canberra, Australia.
Salmon, P., Williamson, A., Lenne, M., Mitsopoulos-Rubens, E., & Rudin-Brown, C. M.
(­2010). Systems-based accident analysis in the led outdoor activity domain: Application
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080/­0 0140139.2010.489966
Stanton, N. A., Baber, C., & Harris, D. (­2008). Modelling command and control: Event analy-
sis of systemic teamwork. Ashgate. Aldershot, England.
Vicente, K. J. (­1999). Cognitive work analysis: Toward safe, productive, and healthy com-
puter-based work. CRC Press. Boca Raton, FL.
White, P. (­2014). Inquest into the death of Kyle William Vassil. Coroners Court of Victoria.
Southbank, Australia.
 21 SAfER Way to
Design Work
Maureen E. Hassall
University of Queensland

CONTENTS
Case Study: Transporting Chemicals...................................................................... 256
Determine Activity and Scope........................................................................... 256
Decomposition of a Complex Activity into Tasks.............................................. 256
Describing Activity/­Task on Decision Ladder................................................... 259
Situation Assessment Analysis...........................................................................260
Lessons Learned through Applying SAfER............................................................ 263
References............................................................................................................... 265

Approximately 360,000 workers die each year from ­work-related injuries (­World
Health Organization & International Labour Organization, 2021). In many systems,
workers are often relied upon to detect and respond to unsafe situations to prevent
and/­or mitigate accidents. If human endeavours are successfully supported by work
systems, this can lead to fortuitous outcomes where safe, efficient, and effective
operations are maintained. However, if h­ igh-hazard industries are not designed to
support the humans responsible for the safety of these systems, then major accidents
can occur. In addition to major disasters, many fatality events also continue to occur
with ­work-related traffic crashes causing the highest number of fatalities in several
jurisdictions.
Examples of major accidents attributed to flawed designs include the following:

• Chernobyl nuclear disaster: It occurred when the reactor became unstable

because the control room operators did not have the necessary information
to monitor where the reactor was operating with respect to its safe operating
envelope (­Det Norske Veritas, 2011).
• Kaprun disaster: Many people were killed because they were unable to
evacuate from the burning train (­Carvel & Marlair, 2015). The 12 survivors
were guided to safety by a volunteer firefighter who knew to evacuate down,
not up, the tunnel (­National Geographic Channel, 2004).
• BP Texas City refinery explosion: This resulted from a tower being over-
filled because the control room operators did not know the actual level in
the tower. The hot hydrocarbon spouted like a geyser out of the top of a
vessel and was ignited causing an explosion that killed 15, injured 180,

DOI: 10.1201/9781003349976-21 253

254 Ergonomic Insights

and severely damaged the refinery (­U.S. Chemical Safety and Hazard
Investigation Board, 2007).
• Buncefield fuel terminal fire: It was also caused by overfilling. The opera-
tors were filling a tank with petrol but due to faulty gauges, they did not
know the actual level in the tank. As a result, the tank was overfilled, and
the spilt petrol formed a vapour cloud that exploded causing massive dam-
age to the terminal and surrounding buildings (­COMAH, 2011).

Historically, the causes of such incidents have been attributed, at least in part, to the
decisions and actions of people responsible for operating the hazardous systems. As
a result, significant effort has been invested to better understand such incidents to
determine how future reoccurrences can be prevented. This effort has included using
human factors approaches to design safer work systems. These approaches can be
normative, descriptive, or formative in nature. Normative approaches focus on how
the human and system should or is intended to behave. Examples of such approaches
include reviewing and refining operator manuals and procedures. Descriptive
approaches are based on how the human and system behave in practice. These types
of analyses can lead to recommendations about improving human knowledge and
skills through better training, procedures, communications, and supervision.
Formative approaches have been developed to analyse the range of ways work
could be done in a system and take the view that there is a broad range of ways
work can be performed within the system. Within ­safety-critical, hazardous indus-
tries, there are often options and variability associated with the way work is done.
For example, novices might approach a task differently from experts. Tasks done in
­high-risk situations, such as a confined space or in hot/­cold weather, might be done
differently to those done in l­ow-risk situations. People under time pressure might
perform tasks differently than those who are not under time pressure. Also, when
performing work, different people and the same person on different days often make
decisions about efficiency versus thoroughness ­trade-offs that can affect task execu-
tion (­Hollnagel, 2009). As a result, I selected to explore using a formative approach
to improve work design.
Formative approaches seek to understand the constraints and ­performance-shaping
factors that influence workers’ selection and execution of work to identify system
design modifications that could help all workers maintain safe and effective opera-
tions across all system states. Cognitive work analysis (­Rasmussen, Pejtersen, &
Goodstein, 1994; Vicente, 1999) and ecological interface design (­Bennett & Flach,
2011; Burns & Hajdukiewicz, 2004; Flach, Monta, Tanabe, Vicente, & Rasmussen,
1998) are examples of formative analysis techniques. In the ­high-hazard industry
sector, applications of these approaches seem to focus on control room operations.
However, for ­safety-critical field and maintenance activities, there were limited ana-
lytical tools to help human factors and ergonomics professionals, or other interested
analysts investigate how to better support the broad range of worker responses that
might be adopted in a h­ igh-hazard industry.
I believed we needed an approach that offered insights into how to improve work-
place designs and better support workers’ ­decision-making, especially when they are
seeking to detect and manage s­ afety-critical situations from both field and control
SAfER Way to Design Work 255

room contexts. My experience across mining, construction, metal manufacturing,

and oil and gas industries highlighted that often workers were required to manually
intervene to keep plants and machines operating and that system designs often did
not prevent unsafe or facilitate safe human-system interactions when manual inter-
vention was required. The engineering design seemed to be done without thought
about human intervention especially in situations when the design did not operate
normally.
As a qualified engineer, I was not sure how to address this gap, so I decided
to study organisational psychology which was informative but did not provide any
solutions. I then went on to do a PhD in cognitive systems engineering that explored
“­Methods and tools to help industry personnel identify and manage hazardous situa-
tions” (­Hassall, 2013). The product of this research was the development and testing
of the Strategies Analysis for Engineering Resilience (­SAfER) technique. The theo-
retical basis for SAfER comes from the field of cognitive system engineering, specifi-
cally from cognitive work analysis, formative strategies analysis, and organisational
resilience principles (­Hassall & Sanderson, 2012).
The SAfER technique is based on the premise that workers’ actions are under-
pinned by their situation assessment, choice, and execution of a response strategy
(­­Figure 21.1). The factors underpinning situation assessments were derived from the
work of Rasmussen et al. (­1994) and Endsley (­1988). The factors underpinning the
response strategy was drawn from the work of Rasmussen (­Rasmussen et al., 1994).

­FIGURE 21.1 Factors underpinning worker responses.

256 Ergonomic Insights

SAfER analysis broadly occurs in two phases. First, the tool helps analysts identify
the critical situation assessment indicators that signal safe versus unsafe operations.
This allows analysts to identify design improvements which could make the indicators
more salient and easier to comprehend. Second, SAfER uses categories to prompt the
analysts to think about the range of strategies that workers might deploy to manage
both normal and abnormal operating situations. The analyst then assesses whether
these work strategies should be promoted, prevented, or tolerated. The outcome of the
overall analysis can then be applied to the work design or other design interventions
required to achieve the objective of promoting, preventing, or tolerating each strategy.
SAfER analysis can be performed on a conceptual system as a prospective risk
assessment technique and during the investigation of actual incidents using the follow-
ing process, which I explain and demonstrate through a case study in the next section:

1. Determine the activity to be analysed and the scope of the analysis.

2. If the activity is complex, decompose the activity into tasks using a
Contextual Activity Diagram.
3. If the range of ways that the activity/­task can be performed is not well
understood, use the decision ladder framework to explore how the activity/­
task might be performed.
4. Complete the situation assessment analysis part of SAfER.
5. Complete the response strategies analysis part of SAfER.
6. Summarise and make recommendations about design improvements identi-
fied in steps 4 and 5.

CASE STUDY: TRANSPORTING CHEMICALS

Determine Activity and Scope
The first step in performing a SAfER analysis, and any human factors analysis, is to
determine the activity to be analysed and describe the activity and its scope. This is
consistent with the first step set out in the international standard for risk management
(­ISO 31000, 2018). When describing the scope of an activity, it is necessary to state
what is included and excluded from consideration (­­Table 21.1) with reference to what
(­activity), who (­people), where (­locations), how (­equipment), when (­time frames), and
assumptions. In practice, it can be helpful to develop a draft of the scope table with
key stakeholders using a process akin to the Delphi approach1 before running a work-
shop with a range of operations personnel. The scope table should be reviewed and
agreed upon at the workshop but doing the draft as prework can make the review
process in the workshop setting more efficient.

Decomposition of a Complex Activity into Tasks

The next step is to decide if the activity is simple enough to analyse in its entirety
or it is perceived as complex and should be broken down into tasks. A tool that can

1 https://­www.rand.org/­topics/­­delphi-method.html
SAfER Way to Design Work 257

­TABLE 21.1
SAfER Analysis Scope Table for Loading, Transporting, and Unloading
Hazardous Chemicals
Description Included Excluded
Activity: It should specify whether it Loading truck with chemicals Manufacture and
includes normal and abnormal Driving truck from factory to packaging of
operations, maintenance, startup, warehouses chemicals
shutdown, etc. Unloading truck Truck maintenance
People: The persons who could be Company dispatchers and drivers Other company and
involved in activity. Client receivers client personnel
Members of public
Locations: Areas where the activity might Factory dispatch area Other factory areas
occur. Public roads Private roads
Customer warehouses in Australia Retail stores
Residences
Equipment: Equipment and plant Loading equipment Other plant and
associated with activity. Truck and its instrumentation equipment on site, on
Unloading equipment roads or in warehouse
Timeframes: When the activity might Anytime throughout year
occur (­e.g. duration, time of the Transport time to cover distance up
day/­days of year, continuously or to 4,000 km
intermittently, within shift/­across shifts).
Other assumptions: Captures any other Compliance with road rules
assumptions made (­e.g. about context). including max driving hours and
hazardous goods requirements.

help decompose activities into tasks is the Contextual Activity Template (­Naikar,
Moylan, & Pearce, 2006). The latter maps activity milestones against roles, or
milestones against work locations, or roles against work locations to identify where
tasks are performed. I found that deciding what categories to use to map activities
is best done by trying all categories to see the decomposition results and then decid-
ing which decomposition produces the best set of subtasks for further analysis. An
example template shown tasks for transporting chemicals is shown in ­Figure 21.2.
Once the activity or tasks to be analysed have been identified, it can also be help-
ful to capture the interactions between people and between people and the system.
Developing a control diagram similar to those used in System Theoretic Process
and Analysis (­STPA; see Leveson & Thomas, 2018 for details) can be used to high-
light key actions and interactions. A simple example is shown in F ­ igure 21.3 for a
truck driver. The truck driver controls the truck through interfaces such as steer-
ing wheel, pedals, gear selector, and dashboard controls. These control actions of
the truck driver are influenced by feedback from the truck interface that indicate
speed, direction, and key indicators of truck status as well as the status of the driver,
the alarms, and the camera information. The company dispatch can also send and
258 Ergonomic Insights

F­ IGURE 21.2 Example of a contextual activity template for loading, transporting, and
unloading hazardous chemicals.

­FIGURE 21.3 Example of control diagram.

SAfER Way to Design Work 259

receive information to and from the truck interface. Inputs into the truck interfaces
can then be converted to actions that control truck movement.

Describing Activity/­Task on Decision Ladder

The next step in the SAfER analysis is to understand variabilities in the way that the
work can be performed. Variability can arise from time pressures (­e.g. rushed orders
might be processed differently than low priority orders), risk levels (­e.g. order involv-
ing highly volatile chemicals might be processed differently than an order involving
inert chemicals), and task complexity. The task might be inherently complex (­e.g. it
might involve a lot of chemicals some of which might be potentially incompatible) or
complex due to its novelty for the people performing it (­e.g. because the task is new
or because the people are new).
To understand the impact of any variability, it can be beneficial to describe these
tasks using the decision ladder framework shown in F ­ igure 21.4 (­derived from Naikar
et al., 2006; Rasmussen et al., 1994). The decision ladder framework shows the dif-
ferent cognitive activities (­rectangles) and states of knowledge (­ovals) that a person
could use in performing a task. It also highlights that people can take shortcuts as
shown by the arrows on the inside of the decision ladder. Testing of the decision lad-
der with industry people and novices highlighted that the decision ladder is difficult

F­ IGURE 21.4 Example of decision ladder template. (­Adapted from Naikar et al., 2006 and
Rasmussen et al., 1994.)
260 Ergonomic Insights

to understand without help but could be usable and useful to promote i­ n-depth think-
ing about how people could perform a task (­Hassall & Sanderson, 2014). Based on
this testing and subsequent work, I recommend that training on the decision ladder
must be provided by skilled trainers so that it can then be implemented by users to
prompt the discussions in the SAfER workshop.

Situation Assessment Analysis

The SAfER table has two assessment sections: a situation assessment section and
a response strategy section. The situation assessment section for the truck driver is
shown in ­Table 21.2. Completing this table involves identifying the ­safety-critical
indicators that will inform people of the system state and then determining how the
design could make these indicators more salient, easy to perceive, comprehend, and
project when required.
The second section of the SAfER table involves identifying the range of potential
response strategies that could be deployed across a system, the possible consequences
of these strategies, whether they should be prevented, tolerated, or promoted and how
this can be achieved through design interventions. To assist with the identification of
a range of possible responses, eight generic categories of strategies are provided. The
categories are (­Hassall & Sanderson, 2012; Hassall, Sanderson, & Cameron, 2014)
as follows:

­TABLE 21.2
Example of SAfER Situation Assessment Analysis Table
What Design Improvements Could
Situation What Indicators Need to Be Make These Indicates Easy to Perceive,
Assessment Monitored to Check for Safe/­Unsafe Comprehend, and Project into the
Indicators Operation? Future?
Equipment Status of truck s­ afety-critical systems:
Oral and t­ext-based warnings with auto
factors brakes, steering, tyres, speed control, safe park feature when ­safety-critical
collision avoidance systems. systems are not functioning as required.
People factors Status including vigilance of driver. • Safe park system for truck if operator
is not present.
• Oral warning system for distracted,
fatigued, unwell drivers.
Tasks factors Location and speed of truck with respect Actual and projected location information
to road: position in lane, clearance from with oral directions and warnings.
other vehicles/­obstacles, and actual vs
planned travel path.
Environmental • Current and forecast weather • Oral warnings and safe park when
factors visibility low, winds high, etc.
• Presence of road/­traffic disruptions • Auto r­ e-routing of truck around
flood/­fire impacted roads to minimise
exposure to disruptions.
SAfER Way to Design Work 261

1. Avoidance category seeks to capture omitting, deferring, or forgetting to

do a task. This would mean that some or all the processes identified on the
control diagram and/­or decision ladder would be skipped. Avoidance strate-
gies can be preferable if it is not safe to continue but they can also produce
adverse outcomes, for example, when an emergency response is urgently
required.
2. Intuitive category seeks to capture the automatic or habitual response that
involves first sensing and then executing without explicitly or deliberately
using cognitive processes. Examples of intuitive responses can be derived
from the decision ladder by looking to shortcut responses (­e.g. those that
go from activation or alert or observe information to procedure or execute).
Intuitive responses are often used by experienced people. They can be ben-
eficial if the intuition is correct but can produce adverse outcomes if situa-
tion is different that the intuitive assessment (­e.g. a driver taking off at green
traffic light without checking for oncoming traffic could be crashed into by
a driver who goes through a red light).
3. Arbitrary-choice category seeks to capture responses that are guessed,
scrambled, haphazard, or panicked. These types of responses can entail no
consideration of options and include just random selection and/­or execution
of a response. Such strategies can be deployed in novel situations where
there is time pressure and no knowledge or experience to inform alternative
options.
4. Imitation category seeks to capture the responses that involve copying oth-
ers or previously successful responses. Imitation strategies often involve
shortcutting the definition and planning processes on the decision ladder.
Imitation is often used to train people on the job and can be beneficial if the
situation and task are identical to the ones imitated. If the situation and/­or
task differ, adverse outcomes might result.
5. Option-based category is when options are chosen without references to
observed or noticed information. This can also involve selecting the first
“­good” option that comes to mind that meets the critical priorities or opera-
tional goals and not trying to find the “­best” option. With respect to the
decision ladder, this strategy can involve jumping straight to a chosen option
by skipping the stages of observing information, diagnosing the state, pre-
dicting consequences, evaluating performance, etc.
6. Cue-based category seeks to capture those strategies that use observed
information and predict consequences through cognitive processes to deter-
mine an appropriate response. These strategies involve using the steps asso-
ciated with situation analysis on the decision ladder (­i.e. the steps on the
left leg of the framework) to identify the chosen option. The efficacy of
­cue-based strategies will depend on whether correct and valid cues were
used.
7. Compliance category seeks to capture strategies that follow authorised
rules, procedures, instructions, and guidelines. These types of strategies
can be effective if guidance is correct and properly applied to the situation
being addressed. For compliance strategies, the action planning steps of the
262 Ergonomic Insights

decision ladder (­i.e. right leg) are executed in a manner that matches the
authorised practices and processes.
8. Analytical reasoning category seeks to capture strategies that use analyti-
cal thinking or mental ­trial-­and-error processes to reason the best way to
perform the task. These types of strategies involve the implication evalu-
ation steps of the decision ladder (­i.e. top part). As such strategies can be
­time-consuming and cognitively demanding, they are best suited when
there is available time and expertise to work through the problem.

To assist workshop participants in understanding the categories of strategies, I found

it helpful to provide a simple example like travelling to work. With such an example,
avoidance might refer to not going at all and working from home instead. Intuitive
might refer to travelling to work using the usual mode (­e.g. own car, ride share, or
public transport), leaving at the usual time and using the usual route without thought.
Arbitrary choice might involve randomly picking the mode, time, and/­or route used
perhaps because they deemed to be about the same. Copying the route or mode that
someone else said would be quicker or easier is an example of an imitation strategy.
­Option-based category might involve taking the public transport bus because it just
stopped outside the front door or going with a friend who was passing by. Checking
traffic reports, public transport schedules, and/­or condition of car before deciding
is an example of a ­cue-based strategy. Compliance strategy could involve using the
route recommended by the navigation system. Analytical reasoning could involve
doing a detailed mental or spreadsheet type analysis to weigh up costs and benefits of
using different modes, times, and routes before deciding.
The SAfER approach seems to elicit the most insights when brainstorming all the
strategy categories for normal and abnormal situations. Shifts in strategies can occur
with changes in time pressure, risk level, and/­or other challenges when performing
the task (­Hassall & Sanderson, 2012). Using the truck driving example:

• The driver might begin driving by following the dispatcher’s and navigation
instructions to travel via roads and jurisdictions where hazardous chemical
transport is permitted (­compliance strategy).
• If the driver hears over the radio that the route has been closed due to a traf-
fic accident, he/­she might select another route previously used to still allow
a timely delivery (­imitation strategy).
• If this route turned out to be more congested than anticipated, the driver
might then seek out information on alternate routes from the navigator
and/­or dispatcher (­­cue-based strategy).
• If whiteout blizzard/­fog conditions turned out to be the cause of the dif-
ficulties, the driver might park the truck safety until conditions cleared
(­avoidance strategy).

An example of the response strategy section of the SAfER table for the truck driving
case study is shown in the Appendix. Once the responses are identified, they can then
be assessed in terms of possible reasons, implications, or impacts. The assessment
should then inform the analyst’s determination of whether the design should promote,
SAfER Way to Design Work 263

prevent, or tolerate each response strategy. If a negative strategy cannot be prevented,

then the design should tolerate it. This means the design should not allow adverse
outcomes to result if the strategy is used. For example, if a human avoids performing
a ­safety-critical function, then the design should have an automated response built in
that will maintain safety.
The last step is to think of ways to make the design inherently safe and more
­user-centred to help workers select and execute strategies that lead to safe and resil-
ient outcomes. This last step is crucial because, based on my experience, most if
not all workers are trying to do the right thing at work and are not trying to cause
an incident or accidents. The incidents or accidents occur when the work system is
designed in a manner that induces or escalates unsafe situations. Hence, improving
the design rather than blaming and retraining or recommunicating to the worker
should produce a more sustainably safe system. I believe that “­to err is human” so
human error should not be considered a cause of an incident but a symptom of a work
system that has not been fully designed for humans.

LESSONS LEARNED THROUGH APPLYING SAFER

I have applied SAfER to a variety of different case studies. Published examples
include crane lifting task (­Hassall, Sanderson, & Cameron, 2016), ship to shore pet-
rol transfers (­Worden et al., 2013), loading road tanker with toxic chemicals (­Hassall,
2013), and work required of a librarian (­Hassall, 2013). SAfER has also been applied
to other industry scenarios, including human-autonomous mining equipment inter-
action scenarios, detecting, and addressing ­high-temperature hydrogen attack in
processing plants and dealing with power outages in a petrol refinery. From these
applications of SAfER, several lessons have been learned.
First, SAfER is best completed with a group of people knowledgeable of the activ-
ity being analysed. This produces a more complete range of s­ afety-critical indicators,
strategies, and design improvements. To ensure all the group members are involved,
it can be helpful to ask each individual brainstorm their ideas first and then bring
them into a group discussion to finalise the SAfER tables. However, as SAfER is a
relatively new technique, training will need to be provided and expectations set as to
the time requirements for a complete analysis. Teaching the scope, control diagram,
and SAfER table is usually relatively straightforward, especially if an easily under-
stood example case study is provided. Teaching the contextual activity template and
decision ladder is more ­time-consuming and challenging because these concepts are
often quite novel for people not exposed to human factors techniques. Instead of
teaching these techniques, the persons leading the analyses might consider doing
these steps themselves and then using the outcomes to guide and inform the group
analyses.
Indeed, the brainstorming process often results in numerous responses for many
of the categories. From experience, some categories, especially the option category,
may not prompt any additional examples of responses. This is often because the
actual response strategy has been captured under another category. This is the second
lesson learned using SAfER: some strategies can be mapped to several categories.
For instance, not doing something could be imitation, avoidance, or intuitive. It is not
264 Ergonomic Insights

essential to define under which category the responses fall because the categories are
just prompts to help people think of a more complete range of responses. Therefore,
the most important is to capture as many ­safety-critical responses as possible.
It is also extremely helpful to explicitly state whether the strategy assessment
relates to normal and abnormal operations. The importance of ensuring safe work
design for abnormal operations (­e.g. startup, process excursions, installation of tem-
porary fixes, shutdowns) has emerged from the analysis of several accidents. For
example, the Texas City refinery disaster occurred during start up (­U.S. Chemical
Safety and Hazard Investigation Board, 2007). The Flixborough disaster occurred
after a temporary bypass was put in place (­Health & Executive, 1975). The Chernobyl
nuclear accident resulted from a process excursion that occurred during when the
reactor was undergoing testing (­International Atomic Energy Agency, 2011). The
Xcel Energy accident was made worst due to inadequate emergency response (­U.S.
Chemical Safety and Hazard Investigation Board, 2010). In addition, I have analysed
other incidents where an unrecognised change that triggered an abnormal situation
such as a deviation from procedure has led to unsafe outcomes.
The third lesson learned is that SAfER was applicable to all case studies tried. It
was even applied to concept systems, and the output could be used to inform imple-
mentation and risk management decisions. It was also applied as a risk assessment
tool, and the output provided insights into design vulnerabilities and how the sys-
tem could be made safer. Furthermore, it was applied to investigate an accident to
determine how future accidents could be avoided. In this case, SAfER analysis was
able to offer insights that would have been identified with traditional incident inves-
tigation approaches and additional insights into system design changes that should
help humans deliver more successful outcomes across a range of different operating
conditions beyond the actual accident scenario. However, it is important to note that,
especially for complex activities, a good analysis can be time consuming and even
tedious.
The fourth lesson learned is that SAfER focuses mainly on human activity and not
technical malfunctions. Therefore, combining several technically focused approaches
(­e.g. HAZID, HAZOP, FMEA) with the SAfER technique can deliver more complete
insights to improve the safety of sociotechnical systems. Indeed, several workshops
have been run by using the same scope analysis and control diagram described in this
chapter. Participants were asked to conduct a traditional HAZID, HAZOP, or FMEA
analyses followed by a SAfER. The results suggested that the insights gained cover
a more complete range of sociotechnical risks, and the recommendations from both
the traditional techniques and SAfER are different but complementary.
In summary, SAfER can help identify ways to improve work designs by prompt-
ing the identification and thinking about the factors that promote good situation
awareness of ­safety-critical indicators and prompt successful response strategies. It
also aims to create systems that acknowledge and deal with the diverse ways humans
can respond to both abnormal and normal operations. As such, SAfER differs from
other human factors approaches that require humans to adopt an “­one correct way”
of performing tasks through the provision of procedures, training, rules, etc.
However, I have found that producing good SAfER analysis requires input
from people knowledgeable about engineering good work systems and people
SAfER Way to Design Work 265

knowledgeable about human-system interactions. I have also found that it takes

effort to identify a succinct set of parameters to inform accurate situation aware-
ness and translate strategies analysis into impactful design interventions. But if
effort is invested, novel but practical insights into how to improve system safety
through design (­rather than just redoing training and procedures) can be obtained
from SAfER. Simply put, SAfER can be a useful tool that complements other tools
used to inform good work designs.

REFERENCES
Bennett, K. B., & Flach, J. M. (­2011). Display and Interface Design: Subtle Science, Exact Art.
Baton Rouge, LA: Taylor & Francis Group.
Burns, C. M., & Hajdukiewicz, J. R. (­2004). EID Ecological Interface Design. Boca Raton,
FL: CRC Press.
Carvel, R., & Marlair, G. (­2015). A history of fire incidents in tunnels. In A. Beard & R. Carvel
(­Eds.), Handbook of Tunnel Fire Safety (­p­­p. ­3–24). London, England: ICE Publishing.
COMAH. (­2011). Buncefield: Why Did It Happen? Retrieved from https://­www.hse.gov.uk/­
comah/­buncefield/­­buncefield-report.pdf
Det Norske Veritas. (­ 2011). Major Hazard Incidents - Arctic Offshore Drilling Review.
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offshore-­drilling-­review-nation_59eec8941723ddf436f3d50d.html
Endsley, M. R. (­ 1988). Design and evaluation for situation awareness enhancement. In
Proceedings of the 23rd Annual Meeting of the Human Factors and Ergonomics Society
(­p­­p. 97–101). Santa Monica, CA: Human Factors and Ergonomics Society.
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SAfER Way to Design Work 267

APPENDIX
Example of the Response Strategy Section of the SAfER Table
What Plausible Should
Strategies Could Strategy Be What Design
Be Used in the Describe Promoted, Improvements Would
System Being Describe Possible Prevented or Help Produce More
Analysed? Reasons Implications Tolerated? Successful Outcomes?
Generic Strategy Prompt: Avoidance - Omit, Defer, or Forget to Do
For normal 1. Loading not Delayed delivery 1. Promote a. Driver receives
operations: complete 2. Tolerate real-time
- Driver does not 2. Driver 3. Prevent communications on
drive truck away unavailable or truck loading status and
- Dispatch does not unaware truck dispatch/ delivery
give driver ready requirements
instructions 3. Driver doesn’t
receive delivery
instructions
For abnormal 4. Truck faulty Delayed delivery 4. Promote b. Truck fitted with ABS,
operations: 5. Traffic incident 5. Promote lane assist, proximity
- Driver does not or road detection, collision
start or stops conditions avoidance, and speed
driving truck means driver control which are
cannot proceed interlocked so truck
cannot start or will
initiate safe park when
safety systems faulty or
have not been serviced
c. Driver’s navigation
instructions based on
­real-time traffic/­road
reports
For abnormal 6. Driver unaware Potential fire, 6. Prevent d. Truck fitted with
operations: of state of environmental automatic load leak
- Driver does not chemicals damage and detection and collection
deal with harm caused to and fire detection and
chemical humans by suppression systems
leak/­ignition leaking/­ignited that alert driver and
chemicals dispatch of unsafe load
conditions
Generic Strategy Prompt: Intuitive - Automatic Response, Done without Explicitly, or
Deliberately Using Cognitive Processes
For normal 7. Experienced Driving while 7. Tolerate e. Require driver to do
operations: driver and all unfit to drive, 8. Tolerate prestart check on self,
- Driver starts previous with faulty truck and load and have
driving assuming occasions were truck, wrong this confirmed by
everything is ok ok load, and/­or dispatch before truck
with driver, truck, 8. Driver in a rush using incorrect can proceed (­possibly
load and travel or distracted travel route with ignition interlocks)
route
(Continued)
268 Ergonomic Insights

APPENDIX (Continued)
Example of the Response Strategy Section of the SAfER Table
What Plausible Should
Strategies Could Strategy Be What Design
Be Used in the Describe Promoted, Improvements Would
System Being Describe Possible Prevented or Help Produce More
Analysed? Reasons Implications Tolerated? Successful Outcomes?
For abnormal 9. Info and alerts Unsafe 9. Prevent As per c. and d. above
operations: have been operations that 10. Tolerate f. Alarm/­alert
- Driver continues mostly false may result in a management system
driving after alerts in past traffic incident that minimises false
receiving alarm or 10. Driver or crash or alerts.
alert. distracted or leaking/­ignition g. System requires both
fatigued/­unwell of chemical driver and dispatcher to
cargo agree on alarm/­alert
response.
h. Driver vigilance
system that requires
safe parking when
driver cannot remain
vigilant.
Generic Strategy Prompt: Arbitrary Choice - Guessed, Scrambled Haphazard
or Panicked Response
For normal 11. Driver Could take 11. Prevent i. Trucks navigation
operations: unfamiliar with longer, less safe systems provides
- Driver guesses route and/­or route, could ­real-time oral and visual
which route, truck deliver to wrong information to driver on
speed, clearances location, could best route, speed and
to use when operate truck lane to use (­designed
driving truck. unsafely (­e.g. with b. and c.)
speeding,
getting it caught
under bridges).
For abnormal 12. Unclear or Unsafe 12. Prevent As per h. above
operations: unfamiliar alert operations that 13. Tolerate j. Simulation and
- Driver guesses 13. Driver may result in a emergency drill training
what an distracted or traffic incident
alert/­alarm means fatigued/­unwell or crash
- Driver guesses
how to deal with
chemical cargo
issues

(Continued)
SAfER Way to Design Work 269

APPENDIX (Continued)
Example of the Response Strategy Section of the SAfER Table
What Plausible Should
Strategies Could Strategy Be What Design
Be Used in the Describe Promoted, Improvements Would
System Being Describe Possible Prevented or Help Produce More
Analysed? Reasons Implications Tolerated? Successful Outcomes?
Generic Strategy Prompt: Imitation - Copy How Others Do It or Copy
What has Worked in the Past
For normal 14. Experienced Might take 14. Tolerate As per c. and i. above.
operations: driver longer, less safe 15. Tolerate k. Investigate truck
- Driver copies 15. Novice driver route, could differences and design
previously used copying how he deliver to wrong options to mitigate
routes and way of or she was location, could potential adverse
driving truck. shown operate truck outcomes
unsafely.
For abnormal 16. Experienced 16. Prevent As per g. and d. above
operations: driver. 17. Prevent
- Driver copies 17. Novice driver
previous copying how he
responses to or she was
alarms shown
- Driver copies Implications:
previous responses could
responses to be wrong
chemical cargo leading to
issues unsafe situations
(­e.g. truck or
chemical
incident).
Generic Strategy Prompt: ­Option-Based - Select Chosen Option from without
Considering Observed Information
For normal 18. Rushed driver Wrong and 18. Prevent As per i. above
operations: 19. Novice driver potentially 19. Prevent
- Driver selects unaware of unsafe route
route without information
referencing provided
information
provided
For abnormal 20. Rushed driver Wrong and 20. Prevent As per i. and g. above
operations: 21. Novice driver potentially 21. Prevent
- Diverted driver unsafe route
selects route
without checking
- Driver selects
alarm response
without checking
(Continued)
270 Ergonomic Insights

APPENDIX (Continued)
Example of the Response Strategy Section of the SAfER Table
What Plausible Should
Strategies Could Strategy Be What Design
Be Used in the Describe Promoted, Improvements Would
System Being Describe Possible Prevented or Help Produce More
Analysed? Reasons Implications Tolerated? Successful Outcomes?
Generic Strategy Prompt: ­Cue-Based - Select Chosen Option Using the Observed
Information/­Cues and Predict
For normal 22. Driver sees Optimum route 22. Promote As per i. and g. above
operations: benefit of used l. Investigate system for
- Driver closely relying on measuring, providing
monitors system feedback and rewarding
navigation good interactions
systems and
consults with
dispatch
For abnormal 23. Driver Safety chemical 23. Promote m. Investigate interactive
operations: understands issues system (­e.g. like Siri)
- Driver refers to importance of for informing driver of
safety sheets to correct chemical chemical cargo
know how to handling
handle chemicals
Generic Strategy Prompt: Compliance - Following Procedures as They Are Written/­Practiced
For normal 24. Driver Transportation in 24. Promote As per j. and l. above
operations: understands accordance with
- Driver follows importance of laws and
road rules, following company
operating procedures policies
procedure, and
dispatch
instructions
For abnormal 25. Driver Chemical issues 25. Promote As per j. and l. above
operations: understands dealt with in
- Driver follows importance of accordance with
emergency following laws and
response plan procedures company
policies
Generic Strategy Prompt: Analytical Reasoning - Using Analytical Thinking to Reason Out the
Best Way to Perform Task
For normal 26. Driver does Delayed delivery 26. Tolerate As per j. provide drivers
operations: not trust system and/­or wrong who want to do this an
- Driver determines route opportunity to do so in
from own detailed the simulator
analysis route to
use
(Continued)
SAfER Way to Design Work 271

APPENDIX (Continued)
Example of the Response Strategy Section of the SAfER Table
What Plausible Should
Strategies Could Strategy Be What Design
Be Used in the Describe Promoted, Improvements Would
System Being Describe Possible Prevented or Help Produce More
Analysed? Reasons Implications Tolerated? Successful Outcomes?
For abnormal 27. Driver Delayed 27. Tolerate As per j. provide drivers
operations: unaware or emergency who want to do this an
- Driver thinks chose to ignore response and opportunity to do so in
about and available incorrect the simulator
develops own information actions
emergency
response
Index
accessibility 30–31, 143, 210, 234 analysis
activities accident 171, 264
agricultural 92 approach 197
assurance 248 basic 191
aviation 165 bias 137
cognitive 259 biomechanical 59
complex 256–264 coding 135
constructive 198 cognitive work 254–255
contextual 258–263 complete 263
daily 56, 142 data 142
data-processing 131 decision 131
decomposition 256–257 demographic 78
description 256–257 document 207
enjoyable 164 environmental 197
farming 97–98 ergonomic 94, 217
harvesting 223 extensive 240
hazardous 191 formative 254–255
high-risk 101, 129 functional 114
human-factors 123 goals 138
improvement 198 human factors 256
industrial 24 inadequate 190
informal 188 incident 167, 245, 264
instructed 243 initial 134–136
intensive 217 methods 251
intervention 62, 198 postural 191
job 32, 97 process 184
maintenance 154, 170, 186, 254 repeatability 134
manual handling 196 response strategies 256, 265–271
mapping 257 retrospective 219
marine 116 return of investment 199
operational 198 scope 256, 264
outdoor 243–244 situation 115, 131, 256–261
participation 163 statistical 56
physical 34 systematic 51
refuelling 157 task 55, 95–97, 112–121
research 72 techniques 254
rewarding 121 template 133–136
risks 174 tool 130, 136
sedentary 30 trend 37, 159, 247
self-directed 199 approaches
simulation 207 accessible 47
sports 170 actuarial 192
structured 170 appreciative 67, 103
supervisory 185 careful 24
swimming 244 change 19
technical 1 codesign 57–62, 220
unique 164 creative 61
unnecessary 149 critical 250
variability 244 descriptive 254
variety 164 design 115–121, 228, 245
work 28, 191 different 137, 219, 233

273
274 Index

approaches (cont.) requirements 75

effective 245 results 17
ergonomics 15, 134–138 risk (see risk)
feasible 80 situation 255–260
formative 254 standardised 73–74
human-centred 94 strategy 264
human factors 72–74, 134–138, 254, 264 tools 36
humane 30 work conditions 36
inclusive 224 workload 121
industry-wide 42 workplace 75
innovative 166 workstation 15
integrated 5–6
investigation 264 care
learning teams 246 aged care 51–62, 207
living document 122 culture 24
localised 57 duty 30, 86–87
mixed-reality 233 patient 143
modified 224 reasonable 82, 86
normative 254 staff 51–62
novel 175, 229 worker 51–62
novice 131 case
participative 197 client 17
proactive 31 clinical 74
problem-solving 58 edge 157–160
risk-based 165–168 frustrating 196
science-based 30 injury 24
sophisticated 197 intervention 51
staged 7 law 85–87
stepped 142 management 54–59, 74, 190
systematic 169 medical condition 24
systems 191–197, 245–250 mock 73
technical 264 studies 123, 129–137, 166, 197, 263–264
top-down 236, 245 unusual 240
traditional 264 challenges
user-centred 247 business 173
user-led 168 communication 36
winning 76 coordination 36
work design 3 financial 173
assessment logistical 79
baseline 82 optimisation 59
clinical 73 professional 249
comprehensive 70 safety 180
ergonomic 14–25, 27–32, 93–95, 209, 221 uphill 31
findings 16–18 work environment 144
formal 74 changes
health 83 arbitrary 146
health and safety 35 behaviour 193
holistic 55, 88 catalyst 75
honest 10 champions 249
individualised 24 context 247
intuitive 261 culture 175
medical 81 document 120
objectives 16 engineer 118
process 199 ergonomic 76
prototype 98 evaluate 60
psychological risk 23 extensive 54
reports 18 formal 146
Index 275

hesitancy 146 ineffective 174

holistic 61 internal 165
impact 95, 248–249 intervention 59
informed 245 lack 200
instrumental 76 lines 18, 69, 117
lifestyle 82 link 186
mandate 193 matrix 114
meaningful 69 methods 24
measurable 95 opportunities 239
necessary 155, 186 poor 5, 45
personnel 7–8 process 58
process (see process) quality 60
ownership 155 skills 59
plans 170–174 spontaneous 58
positive 54, 72 stakeholder 166
practices 62 structured 57–58
proactive 52 systems 19, 198
procedure 146 team 5
prohibit 146 tool 59
reactions 62 trustful 239
regulations 103, 164 written 18
requirements 248 community 78, 124, 147
resistance 18, 72, 196, 244 company
roles 7 advice 190
rule 146 campaign 81
scope 170 commendable 200
sensory 15 compliance 196
sleep patterns 32 concerns 86
software 46 consultants 112–123, 190
standards 103 decision-makers 31
status quo 142 decisions 118
structural 4, 54 departments 228
sustainable 62 direction 85
system (see system) doctor 28–35
task 70 engineering 104, 112
unfeasible 186 experts 98
unrecognised 244 guidelines 113
untested 170 induction 85
updates 248 large 46, 190–195, 238
welcome 73 laundry services 36
work design 29, 41–42, 57, 80, 147 leaders 98
workstation 15–19, 96 logistics 32
communication newsletter 71
challenges 56 obligations 86
channels 46, 186 oil and gas 112
clarifications 4 operations 118, 196
deficit 240 organisational culture 187
documented 58 policies 86, 207–211, 270
effective 3, 24, 59, 164 resources 24, 78
equipment 120 responsibility 115
extensive 124 risk 81
face-to-face 117–120 rules 79, 123
failure 175 software 41–42
flat 224 standards 80
frequent 117 strata 215
friendly 241 sugarcane processing 196
improvements 57–60 third-party 241
276 Index

company (cont.) open 206

tram 215 regular 88, 166
tyre management 102 staff 60, 83
visit 239 stakeholders 7
warehousing 32 user-centred 168
conditions work aspects 224
adverse 217 controls
boundary 237 administrative 190–193
economic 98 centre 112–124
environmental 81, 218, 243 diagram 257–264
health 167–173 document 115–123
low light 210 dynamic 97
medical 24, 27, 142–144 engineering 95
mental 16 ineffective 195
musculoskeletal 14 job 52
operating 264 lose 143, 170
real-world 240 movement 259
unsafe 37, 267 network 207
work 13, 36, 101–106, 182, 218 options 98, 193
concerns process 156
anthromechanical 84 panel 93–95
design 114, 189 peripheral 95–97
health and safety 24, 84, 196 poor 191
investors 107 quality 73
musculoskeletal 196 remote 29
operational 180 room 40–48, 113–118, 130, 253–254
overt 18 smooth 210
reflexive 2 speed 260, 267
safety 65, 95, 105, 244 strategies 70
strident 215 system 112–124, 238–240
widespread 245 team 129
consideration visual 117
broad 93 controller 122, 204–215
careful 118 criticism 11, 196, 213, 232
critical 28
ergonomics 31 decision
operational 167 analysis 131
pre-employment 82 company 118
redesign 67–74 critical 135, 207
risk 70 decision-maker 31–34, 72–75, 129–136, 156,
unbiased 160 186–187
consultant decision-making 2–5, 52–56, 74–75, 129–137,
adversarial 193 164–170
ergonomics 190–201 design 41–44
external 61, 198–200 informed 80
health and safety 27, 196 ladder 131–138, 256–262
human factors 112–124 method 135, 207
management 5 organisational 2
specialist 24 process 134
visual ergonomics 40–42 rushed 185
work design 11 speed 187
consultation stakeholders 122
broad 249 designer 41–47, 84, 159, 208, 218–241
in-depth 213 co-designer 67–75
iterative 240 designs
limited 191 effective 249–251
medical 86 good 42–48, 214
Index 277

redesign 6–10, 28–36, 41–43, 73–75 procedural 199

system 78–85, 138, 181–183, 254–255, 264 review 207
task 66 update 106
work 3–12, 51–62, 65–76, 190–198, 243–250, documentation
254–265 improvement 60
development integrated 199
career 32 intranet 198
concept 239 organisational 56
curriculum 74 progress 198
design 185–186 review 207
economic 87 driver
forums 47 attention 210
habits 19 blind spot 212
internal 165 bus 86
job descriptions 180 cabin 98
organisational 3 comfort 93–96
personal 52 complaints 205
phase 234 consultation 212–214
plan 32 controls 93
product 97–99, 227–236 distracted 260
professional 8, 47 experienced 269
prototype 93 experiences 208
skills 244 familiarity 205
social spaces 219 fatigue 260
software 42–46, 227 feedback 207
standards 107, 114 gaze 210
system 236 hand 208
team 247 interactions 95, 207
training 165–170 knowledge 201
differences learning 212
interface 240 legroom 98
interpretation 137 needs 210
management 48 novice 269
opinion 48 propensity 211
work position 118 resistance 212
discussion rushed 269
collective 150 safety 94–95
dedicated 8 scenarios 211
facilitated 8 seat 91–96
group 263 situation awareness 211
internal 94 state 204
preliminary 94 tractor 91–98, 218
respectful 7 tram 204–215
robust 8 truck 96, 218, 257
sessions 239 unaware 271
unthinkable 230 unwell 260
document vigilance 260
analysis 207 workaround 210
approval 113–120
compliance 141 effect
concept 6 adverse 36, 47
control 113–124 age 167
impact 106 cascade 244
key 7 communication 124
lengthy 151 design 247–251
living 122 environmental factors 36
prescriptive 151 intervention 250
278 Index

effect (cont.) influence 88, 196

leadership 124 local 195
medication 167 major 190
performance 167 motivation 196
presbyopia 43 persuasion 196
project 231 pressures 80
quality 247 responsibility 24, 88
side 79 stubborn 195
stress 36 understanding 81
team morale 72 engagement
work system 33 approaches 61
effectiveness 58–60, 164, 206 content 73–74
employee; see also people; staff; worker conversations 7
assistance programme 84 design 143
behaviour 221 difficulties 7
classification 3 employees 25, 30, 65
communication 24 fruitful 47
deprived 34 groups 168
family members 36 low 61
groups 34 meaningful 4–8
health 13–14, 36, 92 ongoing 200
impacts 87 promotion 52
inexperienced 143 review 143
influence 41 scores 60
injured 31 senior leaders 8
involvement 224 simultaneous 247
less inclined 58 staff 199, 247
lifestyle 32 stakeholders 168, 247
motivation 239 sufficient 167
needs 8 teams 247
onboarding 85 users 44, 168–175, 206–208, 246–247
opportunity 83 wide 176
overweight 85 work 52–56
permanent 181–182 workforce 93
privy 18 engineer
recognition 85 aircraft 153
reports 40, 160 attention 46
rest 36 chief 141–150
reward 85 language 46
roles 7 maintenance 184
safety 92 plant 45
satisfaction 237 process 220
smokers 34 production planning 27
suffering 24, 35 qualified 255
termination of employment 86 ramp 186
training 160 safety 127
upset 40 software 42
voice 24 technical 115
wellbeing 18, 32 environment
employer assessment 14
adversary 195 built 39–48
benefit 196 collaborative 150
communication 18–24 cultural 187
contravention of law 190 external 183
duty of care 30, 86–87 food 82
fund allocation 78 home-like 53–56
improvement notice 190 hostile 183
Index 279

immersive 75 shortage 156

legal 184 testing 186
living 150 variability 244
media 180 ergonomics
natural 147 adviser 66
noisy 144 cognitive 31
office 19 consultant 190, 196
open 150 education 239
operating 164–171 evaluation 232
operational 141 evidence-based 44
organisational 185 legislation 224
physical 52 office 28
political 180 participatory 43–44, 72, 206, 215
proximal 220 physical 31
real 169 practice 200
risks 176 professional 254
safe 30, 108, 150 qualifications 191
safe to fail 229 standards 237
socio-political 180 study 27, 32
stressful 18 tool 31
stressors 35 training 24, 72
team 4 value 201
technical 208 visual 40–48
time-pressured 57 workplace 44, 191
ugly 42 workstation 13, 66
unique 174 evaluation
warehouse 32–33 content 61
warlike 149 design 61
equipment inclusive 98
aircraft fuelling 157 metrics 60
autonomous 263 objective 94
capabilities 172–174 post-implementation 200
characteristics 191 product 93
communication 120 recurring 237
construction 67 regular 249
damage 149, 153 results 199
design 39, 80–88, 159–160, 217 robust 62
expensive 218 seat 94
factors 260 user-centred 245–246
improvements 60 value 196–199
integration 143, 164 example
interface 66 accidents 253
investment 156 analysis 254–260
limitations or limits 86, 217 anthropomechanics 84
maintenance 56 approaches 254
manual handling 56 case 166
manufacturer 220 design changes 96
mining 263 improved practice 61
mock 142 incidents 170
modification 159, 219 interview 59
performance 173–174 real-world 108, 176
protection 158 scenario-based 74
restrictions 81 sector-relevant 167
risks 197 strategies 262–271
safe use 85–88 template 257–259
safety 160 expectations
safety margins 173 clear 85
280 Index

expectations (cont.) contributory 14, 165–170, 245

education course 74 critical 14
high 31–35 design 56
impracticable 102 determinative 160
management 35 downstream 58
minimum 81 environmental 33–36, 154, 174, 260
misinterpreted 66 equipment 260
professional role 73 ergonomic 91–95
realistic 62 genetic 180
social 171 important 222
stakeholder 175 independent 70
experiences influential 187
accident 173 integration 121
adequate 88 interacting 70
capture 134 operational 172
childhood 9 performance-shaping 164, 254
clinical 55 psychosocial 191
combination 223 review 14
common 190, 243 unknown 171–174
design 92–94, 118 upstream 55
diverse 99 work 191
driver 208 failure
engineering 128 boundary 173
exchange 223 communication 175
extensive 136, 191 complete 245
fieldwork 74 dam 107
first-hand 55 exceptional 159
impact 131 hose 158
industry 204 in-flight 153
interactive 75 latent 169–170
lack 228 material 158
leadership 128 mechanical 106
level 136, 168 overwhelming 78
local 131 plant 136
management 154 prevention 129
on-the-ground 243 project 8
participant 62 spectacular 203
practical 227 structural 154
proven 88 systems 169
real-world 80 threshold 171–172
second-hand 134 findings
sharing 58 alleged 150
shopfloor 150 combination 57
sitting 97 communication 215, 224
student 74 damning 212–213
team 11 delivery 214
untold 203 descried 213
user 246 implications 214
visual 75 interview 56
work 143, 183 knowledge-based 128
work-based 75 negative 147
experimentation 138, 150, 224, 236–239 noncompliance 149
positive 147
factors preliminary 171
apparent 91 presentation 73, 171, 192, 213
causal or causative 197, 244 report 3
combination 78 research 203, 227
Index 281

scientific 227 erosion 52

sharing 213 ill-health 13, 60, 187
statistics 157 impacts 36
survey 57–60 initiative 78–85
team 155 issue 54, 153
theoretical 228 management 30, 80–87
unbiased 200 measures 88
mental 14–15, 31–33, 84
group model 66
analyses 263 monitor 36
aviation 175 obligations 86
disability 27 occupational 13, 66
dynamics 11 optimisation 13
ecological 179 policy 160
end-user 175 poor 25, 36
engagement 168 problem 15, 35, 166
facilitator 10 professional 14–19, 54
focus group 58, 74, 104, 206–210 promotion 35
local 62, 188 questionnaire 81–82
muscle 16 requirements 166
needs 65 risks 13–14, 23–24, 56, 79, 148–150
political 179 serious conditions 173
project-steering 54 status 36, 166
reference 214–215 survey 33
research 245–248 system 66
stakeholder 176 team 70
user 237–240, 247–250 theory 74
wider 167 worker 51–56, 79–86
worker 189 workforce 35, 160
working group 107–108 human
activities 264
hazard anthropometry 31
chemical 257–262 capabilities 164
critical 102 capacity 172
elimination 197 endeavours 253
exposure 30 hero 128
extreme 130 injuries 153
handling 157 interactions 112, 237, 255, 265
identification 192–196 intervention 255
inherent 160 knowledge 254
log 68–69 parameters 28
management 198 performance 65, 112, 169–172
musculoskeletal 197 resources 7–9, 65, 83, 155–156, 181, 248
prevention 160 response 264
quantification 191 survival 146
removal 160 systems 244
reports 69–72, 103 wellbeing 112
safety 91, 128 human approach 30
technical 58 human centred 5, 72, 76, 94, 191, 243–248
trip hazard 75, 96, 195 human engineering 156
workplace 191–196 human error 106, 163–169, 187, 256
health human factors 65–72, 74–75, 92–95, 122–124,
assessment 83 254–264
choices 88
chronic conditions 167 ideas
concerns 24, 65, 84 brainstorming 44–48, 263
employee 92 collection 230–239
282 Index

ideas (cont.) magnitude 250

cost-saving 219 negative 247
crazy 241 operations 107, 157, 223
design 46–48, 84, 219, 237 performance 166
diverse 48 physical 208
exchange 219 positive 60, 106, 221–224
implementation 199 productivity 223
improvement 57, 197 project 248
individual 239 reduction 84
literature 35 resistance 84
precarious 220 safety change 250
sharing 58, 73, 103–104 stakeholder 246–247
sloppy 220 survivability 129
unclear 120 underestimated 247
workers 222–224 workload 56
identification workplace 105
abnormal situations 128 implementation
approaches 143 change 46, 195
changes 56 cost 35
concerns 190–196 decision 264
contradictions 238 delays 61
cultural conflict 245 findings 199
design flaws 160 gradual 157
design improvements 256 horizon 7
design modifications 218, 254 integrated 250
factors 55, 264 intervention 198, 250
findings 137 manager 7
gaps 57, 198–199 phase 6, 248–249
goals 237 plan 6–7, 197
hazards 160, 191–198, 206, 255 process 156, 200, 241, 250
impacts 245 progress 7, 200
issues 181–182, 197 real-world 105
knowledge 134 simultaneous 195
limitations 171, 200 successful 7–10
needs 166 systems 199, 248
patterns 136 token 200
problems 40–45, 58, 129, 186–187, 197, 250 work design 7
processes 261 improvement
relationships 237 continuous or continual or continued 54, 61,
responses 260–262 65, 73, 219
safety-critical tasks 182 design 113, 217, 224, 256–271
solutions 52–54 dramatic 18
stakeholders 237 driver seat 97
strategies 52 embedded 58
strengths 103 enablement 48
successes 103 engineering 92
trends 137 equipment 60
users 237 haul truck 102
weaknesses 234, 241 health and safety 35
impacts ideas 57, 197–199
adverse 169 job design 57
age 84 measurable 60
communities 147 operational 218
design 265 operators 218
environment 147 opportunity 92
health 36, 79 plan 37
knock-on 205 process 3, 155–160
Index 283

product design 95 safety-critical 254

productivity 193 scenarios 264
proposal 35, 113 stakeholders 174–176
provisional 190 standard 57, 86, 107
quality 69, 72, 156, 219–220 training 165
rapid 61 trustworthy 108
recommendations 15, 198–199 tyre management 106
request 221 unregulated 244
safety 250 warehousing 32
sustainable 14 information
system 196 accurate 157, 185
tangible 60–61 capture 247
teamwork 60 collection 103, 117, 136, 166, 215, 237–240
work design 55, 197 credible 180
workplace 61, 195 critical 45, 102, 182
incident distil 239
analysis 167 evidence-based 43, 56
causes 254, 263 exchange 240
data 165–171, 244–246 filtering 93
database 166, 249 literature 171
factors 244 necessary 30, 221, 253
form 245–249 nutritional 83
intent 245 observed 261–270
investigation 158, 264 overload 93
personal accounts 137 processing 137
rates 32 recalling 60
reoccurring 127 records 34
reports 165, 189, 243–249 reporting 71
response 127 research-based 83
safety 180–183 review 71
serious 37 safety 103
traffic 267–268 sessions 82
training 248 sharing 57–60, 83, 185, 213
trends 247 sources 134
inclusion 30–31, 166 sufficient 101
industry synthesis 28, 171
aged care 51–55 task 115
airline 190 technology 30, 41, 244–249
aviation 163–176, 185 visual 268
capacity 107 initiative
competitive 190 derailed 85
conference 71 design 11, 223–224
construction 82 health 78–85
cooperation 218 health and safety 37, 54, 103, 245
experience 204 implementation 7, 78–86
high-hazard 127, 253–254 integrated operations 7
investment 107 intent 245
logistics 32 redesign 220
manufacturing 220 senior leadership 150
mining 69, 87, 102–107 successful 78, 219
nuclear energy 179 training 172
oil and gas 112, 127 unsuitable 82
partners 137, 171 workers 223
politics 204 workplace 80–87
practice 85, 236 injury
representatives 165 back 92
research 203 claims 193
284 Index

injury (cont.) evaluation 62, 200

data 54 human factors 176
extent 54 implementation 59–60, 195–198
fatal 104, 154 legal 196
hand 68 limitations 200
manual handling 199 manual 255
musculoskeletal 13 organisational 62
prevention 70 outcome 200
psychological 51–60 participants 62
reports 189 practical 201
risk 14, 23, 70–72 purpose 61
risk management 192 research 61
serious 154 safety 243–251
spinal cord 27 sharing 199
statistics 56 sleep programme 36
integration successful 52–61
business areas 246 tools 163
concepts 5 trial 58
design aspects 122 trust 54
design inputs 116 union 79
evidence 57 unsuccessful 195
options 5 useful 195
participatory tools 236 work design 61, 198
plan 167 workforce 79
technical 234 workplace 35
interactions involvement
benefits 58 active 157
collaborative 61 employees 224
complex 244 ergonomist 30
design 114 industry 165
driver-machine 207 participant 56
guidelines 114 researchers 206
human-machine 93–97 stakeholders 157
human-system 237, 255–265 students 74
informal 61 workers 72
intuitive 232–234 issue
modification 52 chemical cargo 268–269
non-voluntary 185 complicated 6, 79
observation 56 corrosion 154–156
political 108 cultural 185–187
power-related 108 design 79, 113, 186, 205
real-world 48 discomfort 82
respectful 175 discrete 1
safe 141 engineering 112
unplanned 185 ergonomic 44
workplace 11 human factors 120–122
intervention integrity 118–124
academic 231 key 3–7, 115, 165, 189
assessment 200 legacy 107
codesign 58 manual handling 196–197
communication 59, 199 medical 79–87
delayed 25 minimise 250
design 51, 61, 256–265 organisational 8, 182–184
designed with care 52–61 perceived 3–8
dissemination 61 political 8
early 4 quality 149
effective 51, 59, 243 resolution 4, 157
ergonomic 25, 31, 197 resources 7
Index 285

rework 155 iterative 95

safety 153, 180, 270 key 8
social 127 learned 31
structural 9–10 lost 247
systemic 245 opportunities 200
technical 157 project 112
topical 81 levels
usability 205 abstract 114–135, 142
wellbeing 54 acceptable 117
actual 253–254
knowledge automation 114
application 128 company 115
basic 30, 183 complexity 106
building 164 demand 191
capture 128–134 discomfort 15
combination 219 education 47, 73
diverse 55 engagement 52, 208
enhancement 31 equipment 159
enrichment 32 executive 5–8
ergonomics 41–44, 228 experience 136, 168
evidence-based 191 exposure 69–70
experiential 132, 233 field 92
explicit 132–137 force 84
external 188 grassroots 61
gaps 57, 128, 239 ground 79
human factors 122–124 indication 221
identification 134 individual 169
implicit 135–137 knowledge 166
improvement 98 liquid 221
in-house 200 luminaire 36
lack 128 maintenance 153–155
latent 2 middle management 6–8
legacy 176 multiple 244
level 166 necessary 106
leverage 176 neurological 27
limited 181 operational 6–10, 198
operational 138, 197 pain 17
operator 136–137 process 159
practical 197–199 product 221
prior 134, 240 professional 47
probes 207 radiation 182
sources 134–135 safety 79, 182
state 131–134, 259 senior 8, 198
storage 128 stakeholder 31
tacit 55 strategic 141–147
tackling 164 tactical 146–147
task 113–114 team 169
technical 236 technology 160
transfer 128, 200 top 148
type 134–138 training 171
useless 188 workforce 197
user 166
valuable 143 maintenance
worker 128–130 activities 170, 254
aircraft 153–157, 166, 185
learnings aviation 207
appreciated 91 books 185
implementation 200 building 217–220
286 Index

maintenance (cont.) senior 61–62, 149–150, 155–156

capability 147, 153 site 58
crew 69, 187 strategy 143, 169
data 159 style 143
design 185–186 support 60–62
director 146 system 32–37, 87, 197, 249, 268
ease 228 team 105, 175
engineers 184 upper 167
equipment 56 weight 32, 80–87
form 148 workload 164
hangar 145 manager; see also management
heavy 102 contract 69
instructions 158 equipment 69–71
level 153–155 general 69
lighting 36 health and safety 31, 40–42, 104, 196
manager 153–154 human resource 27, 30–33
mining 143 implementation 7
onsite 153 information technology 41
plan 218 line 69
preventive 154 maintenance 153–155
procedures 158 mid-level 6–8
processes 219 mining 103
railway 196 nurse 54–59
records 158 operations 181
requirements 154–157 people and culture 17, 23
schedule 145, 154–159 powerplant 181
seats 77 project 7, 44, 115
sector 223 senior 3–7, 59, 197
supervisor 155 site 54
support 170 warehouse 31–33
tasks 144, 155, 219 meetings
truck 257 brainstorming 156
tyre 101 buzz 58–61
ventilation system 36 committee 7–8
workers 101 evaluation 249
management; see also manager focus group 74
change 18, 155, 243–250 informal 27, 188
commitment 199 interdepartmental 241
company 199–200, 245 kick-off 115–116
consultant 5 minutes 33
crew 164 one-to-one 8
data 156 operational level 6
emergency 9, 244 progress 115
error 164–173 regular 249
hazard 198 stakeholders 213
health 15, 36, 80–87 time allowance 199
level 7, 141, 198 time constraints 7
line 69–72 method
middle 62, 197 analysis 251
model 54 appropriate 250
performance 85 codesign 75
poor 72 communication 24
preventative 169 critical decision 129–136, 207
project 122 data collection 92
quality 153–154, 240 fit-for-purpose 251
regional 69–72 incident reporting 244
risk 66–67, 159–160, 192–193, 256–264 intervention 200
safety 244–248 mixed methods 61
Index 287

observational 95 employer 86
risk assessment 197 feedback 98
risk reduction 30 fonts 41
scientific 99 functional 17
scoring 199 future 85
suitable 250 immediate 31, 61
systematic 199 improvement 94
tested 234 information 28, 151
work or working 196–197 knowledge 129, 200
model learning 74
adaptation 176 operational 142–145, 165
advanced 98 operators 45, 117, 170
appreciative enquiry 103 performance 145
biopsychosocial 56 physical 14–23
cardboard 231–232 population 84
case management 54 prioritisation 17
computer-aided design 231–233 redesign 28, 93, 220
customised 175 rehabilitation 28
development 231 reporting 248
dummy 234 resources 248
dynamic safety 168–175 rest 34
educational 74 rework 155
existing 93 self-determination 5
four frames 8 skills 200
harvesting machine 219 staff 142
healthy workplace 82 stakeholders 44, 247
improved 98 students 74
job crafting 53–61 training 163–167, 263
mixed-reality approach 234 tram drivers 210–212
modification 231 understanding 95
operations 7 unique 164
physical 228–234 urgent 17, 192
plan-do-check-act 2 users 84, 99, 168–171, 239–250
real-looking 232–233 work 142
relevant 228 workers 14, 28, 108, 150, 223
role 11–12
small-scale 101 operations
theory X theory Y 5 agriculture 218–220
threat and error management 168–175 aviation 144–150, 153–160, 163–176
tractor 97 integrated 5–8
training 165 mining 87
work engagement 53 oil refinery 130–134
powerplant 180–186
needs safe 87, 113, 164, 171–173
adaptations 184 transport 256–271
assessment 17–24, 200 tyre management 102–107
business 251 unsafe 256
care 57 warehouse 32–37
changes 157, 181 operator
client 58 aircraft maintenance 158–160
communication 117 aircraft pilot 164–176
company 85 machine 218–219
competing 185 mining 101–107
compliance 113 oil refinery 129–137
data 28 room 41–47, 113–120
diverse 67 truck 77–87
elimination 222 organisation
employees 8 actions 250
288 Index

organisation (cont.) requirements 247–249

adaptation 88 resilience 255
aims 53 resources 5, 52, 193
appetite 54, 229 restructuring 4
aviation 153–154, 164 rules 144
benefits 224 safety climate 31–35
bureaucratic 145 senior management 54
change 5–10, 53–54, 154–156, 183–184, 245–249 size 157, 164
committee 5 strategies 222
complex 1 structures 10, 141, 155, 220, 237
conscience 184 support 219
construction 66 system 30, 88, 244–249
context 55–59, 157–159, 164 training 101
costs 57 values 53–56
cultural maturity 37, 151 outcome
culture 56, 103, 156–157, 187–188, 224 adverse 173, 261–263
data 248 change 61
defence 147 client care 54
directives 145 communication 198
documentation 56 comparison 1
efforts 154 design 59, 187
elements 2, 11, 153 desired 11, 174
environment 185 disappointing 45
experimentation 224 disastrous 128
failures 224 durable 197
focus 62 evaluation 199
future 103 favourable 9
goals 58 fortuitous 253
governmental 3 intended 142
guidance 182 organisational 1
human-centred 76 positive 52
idea 106 practical 199
information-sharing 57 productive 218
intervention 51, 62 professional 200
issue 8, 182 rational 7
large 150 review 198
leaders 5, 13 suboptimal 8, 124
learning 244 surprising 213
levels 142–147, 155–156, 244–247 sustainable 62
maintenance 153–154 unanticipated 208
management 105, 156 unsafe 264
missions 154 work 52–57
needs 248
objectives 224 participant
pitfalls 181 brainstorming 104
policies 60, 160 comments 199
politics 10–11 communication 237
powerful 190 competition 163
practices 60–62 confidence 61
priorities 62 course 197–199
problems 8, 154 experience 62
procedures 60, 144, 159 feedback 199
processes 10, 62, 155, 248 integration 242
project 104 intervention 61–62
readiness 35 motivation 231
receptive 224 responses 62
reputation 107 together 61
Index 289

training 198–199 evaluation 169, 261

workshop 262 factors 164, 254
participation feedback 53
active 57, 230 high 14, 153–154
culture 157 improvement 52, 224
limited 61 increased 14
low 61 indicators 36, 205
quality 61 job 14, 53
social 28 low 8
staff 58 management 80–85
voluntary 15, 83 margins 166
worker 54, 143 measured 1
workplace 57 monitored 1
people; see also employee; staff; worker motivate 35
ability 207 optimisation 14
disabilities 27–36 outstanding 129
eager 10 peak 187
empowerment 108 pressures 187
engagement 52, 246–249 product 92–93
experience 48, 128, 224 resilient 67
experienced 261 review 74, 85
feelings 128 supervised 142
frontline 105 sustainable 52
goals 5 system 85, 147
imaginative 31 task 149, 180
industry 259 threshold 173
intelligent 2 unacceptable 173
interactions 257 variability 143
involved 5, 182 work 70
key 7 phases
knowledge 128, 263–264 analysis 240
needs 184 build 168
overweight 84 critical 144
perceptions 205 decision-making 131
respect 53 decisive 232
responsible 254 design 7, 67–75, 157, 247–251
roles 220 development 234
safety 151, 244 discovery 55–58, 66–74, 248–251
shortcuts 259 flight 169
sleepy 35 implementation 6, 241, 248
somnolent 35 operations 181
stories 9 preflight 144
training 261 procurement 42
transition 207 project 112–124
untrained 24 realisation 71–75, 248–251
wants 4 research 239–240
performance shaping 232
acceptable 171–174 sketching 229
aircraft 171–173 successive 237
aspects 73 testing 241
boundaries 172 transitional 248
business 57 plans
capability 165–174 action 32, 155
capacity 14 agreed 23
engine 102 change 170–174
envelope 173 crafting 28
equipment 173 development 1, 32, 173
290 Index

plans (cont.) neutral 16, 97

discussion 17 operator 116–117
effective 32 powerful 123
floor 191 scale 194
health management 80–87 sitting 19–23, 95–97
implementation 6–7, 32, 197 standing 23
improvement 37 steering column 84
integration 167 stowage 158–159
lighting 118–119 work 116–120, 191
maintenance 218 practices
response 132–137 actual 104
rollout 246 advanced 91
shared 58 agricultural 91
treatment 87 authorised 262
well-thought 80 best 42–45, 53–56, 80–85, 117–122
plant clinical 39
closure 180–183 common 67, 114, 182, 218
condition 131 design 65–66
drawings 132 design-in-use 219
drift 182 emerging 150
engineers 45 ergonomics 196–200, 208
industrial 41–42 healthy eating 82–83
knowledge 130 human factors 112, 208
limits 86 improved 61
manager 128 industry 236
mechanics 67 management or managerial 2, 72
mobile 67–71, 77 opportunity 101
nuclear power 179–183 organisational 56–62
owners 180 robust 48
processing 102, 263 standard 79–85, 154–159
safe use 85 supervision 182
safety 132 valued 107
state 131 work 54–56
visit 182 presentation 73–75, 93, 165–168
workers 182 problem
position ambitious 59
agreed 8 approach 176, 191, 241
chair 16 capture 213
comfortable 213 central 57
company 85 clarification 240
console 116 complex 6, 98
corner 16 definition 171
dangerous 196 design 187, 219–222, 250
default 1 developmental 31
defending 149 discovery 40
department 87 discussion 3
display 40 emerging 159
employer 87 ergonomics 44–46, 113
food pedals 84 escalation 157
head 16 experience 220
high-risk 173 fixing 79, 186
keyboard 16 functional 223
legal 80–86 health 15, 35, 166
low-risk 173 hearing 34
luggage 193 identification 58, 144–148, 186–187, 219
mouse 16 information 156–157
neck 16 interface 41, 205
Index 291

interpretation 196 poor 172

knowledge 105 predetermined 169
language 188 prescribed 144
long-standing 176 review 143
manual handling 197–200 revised 146
mismatch 107 systems 81
novel 129 time-consuming 122
organisational 8 work 32–35, 221
orientation 196 work design 141
overload 116 workplace 85
perceived 93 process
quality 51 administrative 244, 248
real 119, 250 approval 19
real-world 205 assembly 105
rectification 159 assessment 199
report 160, 219 brainstorming 219, 263
response 223 certification 184–185
safety 183 change 6, 249
serious 107, 183 co-design 28, 61–62
share 213 cognitive 261, 267
source 40 communication 58
statement 94 conditions 116
structured 54 consolidation 5
understand 52, 247–250 contractual 46
unresolved 41 control 122, 156
view 176 critical 44
vision 43 data 238
workplace 160, 197–200 debriefing 130
procedure decision 75, 134
abstract 150 deviations 127
accessibility 143 diagram 238
assumptions 157 discovery 56, 247
authorised 261 dispute 193
change 146, 248 engineering 123
codified 157 ergonomics 95, 206
compliance 103, 143–145, 234, 261, 270 evaluation 135, 200
comprehensibility 143 expensive 184
constraint 143 flow 117
creation 143, 160 flowchart 238
design 143–148 formal 73
deviation 264 graphics 113–120
documented 56, 143–147 implementation 200, 241, 249–250
drift 143 improvement 3, 154–160, 219
efficient 235 industry 112, 127
established 132, 142, 158, 239 integration 248
formal 170 interdependencies 239
imposed 146 iterative 246–247, 250
inextricable 141 learning 11, 187, 244, 250
integration 164 legal 190
interview 240 level 159
local 146 maintenance 219
maintenance 158 management 175, 198, 244, 249
management 143 manufacturing 238
mandated 158 mechanisation 217
operating 143, 199 operators 116–117
operational 173 organisational 62, 248
organisational 60, 159 participative 61, 206, 232
292 Index

process (cont.) productivity 14–25, 30–35, 65–72, 219–224

planning 92, 261 project
policies 157 background 212
procurement 29 benefits 124
production 57, 239 celebrate 71
rating 184 change 5–7
realisation 247 communication 124
recruitment 81 complexity 237
recursive 57 conditions 237
redesign 6, 75 constraints 114
reflective 11 consultancy 41
reporting 58, 244 design 7–11, 44
review 207 experiences 241
revised 7 fixed price 112
safety 127 flow 185
screens 120 funding 54
staged 200 goals 250
supervision 116 impacts 248
uncomplicated 75 industrial 123
units 112–120 intervention 31
unsuitable 6 investment 120–124
useful 135 language 116
product large 83, 123
appropriate 45 lead 115
approval 184 leadership 124, 245
aspects 92 management 122
base 42–46 methodology 212
built 45–46 oil and gas 123
catalogue 119 opportunities 54–57
comfortable 95 partners 229, 236–238
design 92–98, 206, 227–232 phases 112–123
designer 94 practical 228, 239
development 97–99, 227–228, 236 product design 232
ergonomic 227 profitable 104
evaluation 93 promote 55
final 175–176, 185–187, 229–233 realisation 62
future 98 research 129
hand-held 232 review 99
industrial 227–229 sponsor 7, 54, 241
lighting 45 stakeholder 124
new 96–98 steering group 54
performance 92–93 success 40, 62, 71–72, 124, 239–241, 247
physical 228 support 245–247
prototype 94–97 teams 3–6, 115
representation 228 timeline 46
safe 95 unusual 92
tangible 233 provision
trial 69 advice 16
useability 228 budget 199
workable 247 care 57
production documents 238
capability 91 information 157, 238
error 238 legislative 190
line 210, 221, 238–240 procedures 264
model 236 protective 92, 194
process 57, 239 rules 264
system 114 security 194
team 128 training 182, 264
Index 293

recommendation workforce 184

acceptance 6 workplace 115
application 200 reports
appropriate 14 accident 105–107, 142
feedback 115 annual 56
implementation 17, 128 approval 118
implications 213 assessment 18
improvement 15, 198 biases 167
intervention 200 detailed 17, 156
investigations 128 ergonomics 48
redesign 99 form 245–249
refusal 118–121 hazard 69, 103
translation 45 incident 165, 189, 243–249
work design 195 informal 7
relations 66, 75, 78, 182 investigation 128
relationships management 69
building 56, 176 preparation 199
collaborative 47 safety 103
collegial 143 sharing 83
good 44–46, 228 study 118–122
nature 52 traffic 262, 267
professional 48 typing 28–29
satisfaction 60 worker 191
symbiotic 62 writing 212
team 4 research
trust 61 academic 218
requirements accessible 78
additional 249 activities 72
airworthiness 184 anthromechanics 84
analysis 237–241 assistance 216
change 248 assistant 206–211
definition 239 costs 185
design 47, 118 critical decision method 130
employment law 37 cursory 33
environmental 114 emerging 13
foundation 82 extensive 98
health and safety 87, 106, 166 fellowship 204
inherent 78–87 findings 203, 227
job 78–88, 115 freedom 229
legal 124 group 245–248
maintenance 153–157 industry-focused 203
management system 87 intervention 61
mandatory 28 laboratory 218
minimum 124 market 92
new 80, 237 online 28, 69
operations 4, 248 partners 249
organisational 247 phase 239–240
partners 249 product 255
role 87 project 129
stakeholders 43 proper 176
surveillance 183 related 32
task 28 scientific 112
time 263 researcher 206–214, 223, 245–246
understanding 97 resources
user 47, 156, 237 access 82, 105
work 187 additional 156, 248
work design 10 adequate 53
work organisation 115 adjustment 53
294 Index

resources (cont.) employer 24, 88

allocation 35, 59, 97, 199, 247 group 107
available 52, 155–156, 186 health and safety 35, 141
company 24, 78 identification 6
financial 199 implementation 123
impact 52 manager 54, 59
implications 145 new 154
inadequate 51 professional 124
in-house 78, 198 restructuring 53
insufficient 41 subcontractor 124
internal 200 supervisor 4
job 52–60 team 123
limited 193 unclear 238
mental 159 worker 220
natural 187 results
necessary 37 adverse 142
organisational 5, 52 assessment 17
reassignment 186 communication 5
social 59 decomposition 257
staff 53, 248 discussion 9, 137
technical 223 engineering 118
worker 249 expected 173
response good 124, 232
actual 263 inconclusive 61
adjustment 157 integration 112
appropriate 261 intermediate 238
aspects 134 interpretation 112
automatic 263–267 optimal 121
capture 261 poor 17
client needs 58 pride 121
coordinated 3 promising 136
delays 146 representative 137
different 132 survey 34
emergency 261–271 unexpected 143
forced 204 useable 192
formal 146 review
guessed 268 accidents 170
habitual 261 appetite 175
haphazard 268 approach 175
intuitive 261 changes 190, 248
non-rational 5 checklist 33
options 132–134 constant 187
panicked 268 consultant 123
plan 132–137, 270 controls 56
positive 165 critical 144
possible 260 curriculum 74
quizzical 65 cursory 170
safety-critical 264 data 165–166
scrambled 268 decisions 187–190
strategy 130, 255–271 design 113–120
successful 261–264 detailed 174
worker 254–255 documentation or documents 56, 121, 207
responsibility draft 165, 247
acceptance 193 educational course 74
area 32 effectiveness 58
changes 155 equipment design 84
company 115 ergonomic 24
Index 295

evidence 57 health 13–24

exposure 86 hypothermia 243
extensive 54, 135 identification 92–94, 192
factors 14 inherent 54, 106, 192
formal 123 injuries 13–23, 58, 67–72, 79, 190
goals 96 integrity 124
human factors 123 legal 182
incidents 166–170 level 190–192, 259–262
information 166 management 66–67, 79–87, 154–160,
job description 172 192–193, 256–264
learnings 91 minimise 150
legal position 86 mitigation 32, 67, 174, 192–198
literature 142, 166–171, 218 musculoskeletal 13, 57–58, 67–69, 81, 93
manuals 254 nature 55, 164, 192
objectives 96 new 105
opportunity 56, 200 obesity 82
outcomes 59, 198 operational 148, 165–173
performance 74, 85 perception 174
policies 56 potential 105
post incident 77 practices 104
procedures 143, 254 prevention 174
process 130, 185, 256 profile 32, 61, 167
progress 83–85, 193–195 psychological 18, 57–58
projects 99, 198 psychosocial 31
regular 56, 88 radiological 183
regulatory 193 reduction 30–31, 57, 70, 192–193
reports 69, 165 reporting 197
responses 132 reputational 78
rostering 54–57 safety 23–24, 79, 94–96, 120, 148
scope 256 score 192
situation 195 side 105
standard 107 slips/trips/falls 67, 95–96
tractors 92 sociotechnical 264
training 77 sources 57
work 135, 200 technical 55, 159
work area 28 tolerance 171–173
workstation 14–15 training 165
risk unacceptable 192
acceptable 124, 193 unintentional 150
additional 105, 146 unique 163–170
assessment 2–35, 68–70, 93–97, 105–106,
190–198, 256–264 safety
aversion 171 actions 107
awareness 123 analyses 197
biomechanical 58 authority 205–207
collision 67–70 awards 105
controls 35, 79, 144, 193–200 briefing 182
critical 101–108 capacity 86
cumulative 70–71 challenges 180
decision-making 211 change management 243–250
environmental 164 chemical 270
ergonomic 94 climate 31, 35
experimental 150 concerns 105, 244
exposure 32, 86, 174, 222 culture 35
factors 18, 51–58, 66–70, 93–98, 191–197 data 245, 248
fatality 72 design 106, 265
foreseeable 37 drivers 95
296 Index

safety (cont.) rated 78–87

flight 144, 166 redesign 93
harness 81 replacement 78–79
hazards 91, 128 shape 97
improvements 250 standard 77
incidents 180–183 tractor 91–97
information 103 truck 77–79
initiatives 103, 172, 245 vehicle 77–81
interventions 243–251 situation
issues 153, 180–184 abnormal 127–138, 256–264
legislation 87, 224 agile 187
level 182 awareness 74, 212, 264–265
management system 207, 244, 248 comfortable 229
margins 154, 173 complex 128
measures 156–158 complicated 103
model 168–173 control 143
obligations 86 critical 256
operational 145 different 120, 261
patient 58 difficult 241
plant 132 diverse 217–219
policies 160 emergency 208
problems 183 future 129
psychological 33, 60 hazardous 255
psychosocial 56 high-risk 23, 254
record 179 ideal 87, 236
reports 103 identical 129
requirements 106 insecure 183
risks 23–24, 79, 94–96, 120, 148–150 low-risk 254
science 245 mitigation 190
signs 107 novel 261
standards 222 off-normal 117
system 215, 267 remedy 15
technology 172 repeated 119
training 172 review 195
seat safety-critical 254
access 95 uncomfortable 3
adjustable 23, 97–98 unfamiliar 143
adjustments 95–97 unfolding 169–180
arm 208–210 unsafe 253–269
belt 84 urgent 18
bus 86 win-win 25
car 23, 233 worsened 24
comfort 94 software developer 41–46
cover 95 solution
design 92–97, 208 adequate 183
driver 91–97 agreed 219
features 97 alternative 238–242
functionality 77 analysis 186
issues 208 application 57
levers 97 bespoke 42
maintenance 77 brilliant 11
new 78–79 built 44
old 78 clever 222
original 80 constructive 6
pan 15–21 contemplation 87
pedal 97 co-ownership 157
price 78 crafting 52
Index 297

customised 222 ancillary 44

design 8–11, 44–47, 57, 250 awareness 60
development 57 breaks 4
effective 11, 219–224 capacity 145–146
efficient 72 check-in 190–191
endorsement 8 competent 155
engineering 79, 215 complaints 155
established 241 curious 61
evaluation 55, 199 enablement 58
examination 69 encouragement 58
expected 93 engaged 61
expensive 180, 215 experienced 143–148, 183
feasible 58 feedback 60
generation 58, 98 field 72, 244
good 40, 106 frontline 82, 244–245
ideal 222 harm 144
identification 52 health and safety 37
implementation 5, 52 healthy 36
individualised 30 implications 141
interim 249 increase 58–60, 98
interpretation 196 injured 147
inventor 219 international 188
lighting 47 leaders 60
limited 183 licenced 147
mixed 182 limited 59
obvious 155 motivation 9
one-size-fits-all 166 needs 142
optimal 43 operational 245–247
perceived 93 perceptions 60
possible 43, 156, 238 permanent 41
potential 69 perspectives 54
practical 104 qualifications 248
preferred 195 reports 60, 191
reasonable 183 requested 59
replicated 219 resources 159, 248
risks 105 risks 60, 150
robust 168 rooms 56
selection 58 safety 58, 160
simple 221 shadow 56
suitable 105 shortages 51, 145
sustainable 108 supervisory 197
system-wide 246 support 44
temporary 15 trained 53, 158–159
testing 219 training 59, 156–159, 248
timely 24 warehouse 32
worker 220–222 workload 159
specification stakeholder
clear 94 commitment 124
design 81, 115, 158 communication 166
furniture 121 consultation 206
job 27 decision 122
manufacturer 80 engagement 167–168, 247–250
technical 93, 160, 240 external 80, 175–182
staff; see also employee; people; worker feedback 121
absence 4 frontline 157
activities 56 impact 246–250
administrative 32–36, 245–246 industry 174–176
298 Index

stakeholder (cont.) procedure management 143

insights 250 prompts 267–271
internal 174–176, 247 risk management 79, 160, 169–173
involvement 157, 181, 236 rollout 246
key 87, 251–256 safer 130
meeting 213 selection 134
needs 185, 247 shift 261
requirements 43 surveillance 181
responsibilities 99 survival 9
urgencies 185 work 256
standards work design 65
accreditation 73–75 workforce 65
amendment 103 workplace 36
Australia 103–108 support
Canada 57 ability 171
care 57 accessories 18
company 80 actions 143
compliance 72 adaptation 88
high 54 administrative 199
human factors 124 company 198
industry 57, 86, 107 co-worker 52–53
international 28, 153, 256 dedicated 153
ISO 237–238 design 247–250
legal 87 error prevention 237
management 102 feet 17
minimum 80–82 financial 224
national 196 flight operations 155
outdated 108 formal 219
poor 79 furniture 18
rail 215 human performance 169, 253
recognised 106 implementation 250
safety 222 instrumental 61
Singapore 28 IT 44
update 108 leadership 245–246
standardisation 103 level 8
strategy low back 92
analysis 265 lumbar 16–22
assessment 264 maintenance 170
avoidance 261–262 operational 69
business continuity 37 peer 75
capture 261–262 personnel 128
categories 260 physical 19
combination 14 problem solving 59
comfortable 24 process 169, 238
common 185 programme 81
compliance 222, 261–262 progress 198
control 70 project 247
cue-based 261–262 resources 143
deferred 19 safety 243
development 9 scaffold 159
formative 255 senior executive or senior management 8, 62
identification 52 services 83
imitation 261–262 supervisory 52–61
improvement 263 team 69
integrated 195 useful 190
negative 263 weight 159
practical 174 wellbeing 18
Index 299

wrist 17–18 critical 127, 149, 182, 213

system data entry 40
aircraft 144, 154 decomposition 256–257
analysis 251 delegation 182–183
avionic 186 demands 172, 220
capacity 145 design 66–69
change 4, 247 difficulty 159
complex 128 distribution 241
computer 29 duration 154, 172
conceptual 256, 264 efficient 68
critical 144 essential 5
development 227–242 execution 190, 254
dual 249 expanded 52
elements 95 experience 108
events 244 expertise 215
failure 169 explore 256
fault 154 exposure 70
features 237 forget 260
hazardous 128, 254 knowledge 113, 180
health 66 load 30, 212
high-risk 173 low risk 131
human 244 maintenance 144, 155, 219
improvement 196 manual 66–72, 87
integrity 151 meaningful 80
intervention 250 menial 67
legacy 248 modification 52
legal 196 non-essential 31
level 52, 191 observe 104, 145
modification 254 office 120
navigation 262 operational 180–183
organisational 30, 88, 249 overload 35
parameters 95 ownership 160
performance 85, 147 performance 149–151, 157, 181, 254–270
processing 112 preventative 155
production 114 quality 172
revolution 76 redesign 105
safe 263 reduced 52
safety 215 requirements 28, 220
socio-technical 245, 264 scope 52
state 254, 260 separation 155, 182
sustainability 199 solutions 69
targets 237 supervisory 145
technology 249 support 247
tolerance 174 tailor 171
training 247 understanding 165
ventilation 36 unrelated 155
workable 118 variety 52
systems thinking 143, 164, 207–208, 250–251 visual 114
volume 154
task team
adaptation 72 communication 5, 94
allocation 114–115, 131 core 249
analysis 97, 112–121, 182, 197, 217, 257 dedicated 42, 155
cognitive 117 design 97
compelling 185 engineering 92–96, 115–123
complexity 60, 102, 259 environment 4
computer 43 experience 11
300 Index

team (cont.) trainee 101, 148, 167

extra 144 trainer 83, 260
health and safety 70, 106 training
innovations 218–224 amount 156
interdisciplinary 241 application 164–165, 200
internal 175 appropriate 183
involvement 248 aviation 165
large 4, 123, 154 class 101
leader 68–71, 128, 149, 156, 218 content 175
learning 197, 246 course 167
members 3–10, 92–96, 169–175, 246 cursory 170
morale 72 development 165–168
multidisciplinary 46, 123 effective 164
novice 98 emergency 268
open 97 engaging 165
operational 117 ergonomics 24, 72
operations 170 evaluation 198
performing 14, 147, 156 facilities 163
pleased 97 formal 101, 170, 183
proactive 224 forums 68
problems 218 gradual 148
project 3–6, 115–116 human factors 164–165
reactions 95 improved 193
rescue 79 induction 81, 182–183
response 132 in-house 80
roles 4, 43 initiatives 172
senior leadership 215 inspirational 72
small 3, 170, 246 integration 200
suggestions 155 investment 164
supervisor 4 issues 182
support 69 lack 181–182
technical 145–149 legacy 175
trained 198 levels 171
training 249 materials 32, 56
teamwork 9, 55–60, 143, 251 missions 147–148
time modules 168–170, 248
additional 113 necessary 183
allowance 199 needs 167
available 59, 262 objectives 199
constraints 2–7, 30–35, 70–75, 130 on-the-job 142, 150
consuming 113, 120–122, 234, 262–264 packages 164–169, 176
ideal 61 participants 198–199
intervals 154 periodic 128
investment 138 poor 191
lag 78 programme 102, 128, 164, 176, 199–200
limitations 30–33, 142–149 provision 182
lost 192 qualification 248
pressures 52–58, 247–248, 254–262 requirements 164, 248
processing 236 sessions 83, 182
reasonable 119 systems 247
requirements 263 tailored 174
reverberation 118–119 targeted 56
staff 159 teams 3, 198, 249
timeframe 154, 256–257 time 59
timeline 46, 59, 134–135 workshop 59, 101
training 59
travelling 34 weight
usual 262 acceptable 192
Index 301

bag 192 expectations 221

consideration 158 experienced 143, 150, 224
desired 86, 233 exposure 222
distribution 22 field 66, 72
goals 83 frontline 104, 127–134, 155, 244–249
hose 158–159 health and safety 34, 60, 79–81, 88, 263
increase 87 humiliation 84
limb 208 ideas 222
limits 81, 190 incapable 87
loss 78–87 inclusion 224
management 32–36, 86–87 inexperienced 150, 180–182
maximum 81–87, 190–192 influential 62
nominal 191 information 221
physical 233 initiatives 223–224
range 79–87 injury 23
rating 79–86 innovation 220
reduced 154 inspired 69–72
reel 159 inventiveness 223
required 85 involved 72
restrictions 81 knowledge 105, 128
scanner 229 lifestyle 82
target 83 local 188
tolerance 77–80 mistake 181
worker 80–86 motivation 53
work; see also workplace needs 14, 108, 223
good 52–55, 203–215, 243–249, 264–265 office 31
safe 30–35, 57, 105, 264 opportunities 52
unsafe 37, 187, 253–269 overweight 78–87
worker; see also employee; people; staff participation 54, 143
absent 84 perception 56
autonomy 219 permanent 181–183
behaviour 193 perspectives 221
benefit 196 practices 219
capacity 13 proud 223
care worker 51–59 redeployed 85
characteristics 56 rehabilitation 28
commitment 68 reports 191
consultation 72, 78, 224 rights 56
co-worker 52 risks 87
decision-making 244, 255 shift worker 34
demands 194 shop floor 105
desk 13 solutions 69, 220–222
determined 70 strategies by 221
disability 27 suitable 82
dismissed 87 support 78, 137–138
diverse 80 temporary 180–183
duties 194 training 128, 181, 244
engagement 86, 105, 196, 206 trust in 151
enthusiastic 72 workplace 18, 56, 61, 224; see also work
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