Twenty years ago, I completed my PhD on human factors in air traffic control. Part of the study involved developing a taxonomy to describe cognitive errors and associated performance shaping factors. The taxonomy was known as TRACEr (Technique for the Retrospective and Predictive Analysis of Cognitive Errors) and was designed to be used for a variety of purposes including incident analysis, observation, and, along with a task analysis, human error identification for new tasks (see Further Reading). TRACEr had been in development for six years and was tested with hundreds of incident reports ..read more

This article is a reproduction of an article published in HindSight magazine issue 35 in September 2023 (all issues available at SKYbrary) What is ‘human error’ anyway? It’s a good question, and one that is surprisingly difficult to answer. There is little agreement on what ‘human error’ means. Psychologists prefer to define errors according to deviations from intentions, expectations, cognitive processes and states, or personally preferred outcomes. Safety and design specialists may refer to deviations from norms, rules and standards, such as those prescribed in ..read more

Since I starting blogging, I have written posts on a range of topics concerning work and life. I write to help to make sense of and record my thinking, and communicate this in case it is helpful to others. One of the reasons I chose to divert some energy toward blogging and away from academic publication was accessibility and control of content and publication. Most of my work is translational, not empirical research (though some is), and I prefer to communicate in a way that is accessible to as wide a group as possible. But I realised after a few years that it was not so easy to find (or even ..read more

Understanding the complexities and nuances of human work is critical if we are to improve how work really works. In healthcare, as clinicians and other healthcare professionals navigate their roles, they encounter a diverse array of situations that create goal conflicts, dilemmas and other challenges. One way to explore these is via micro-narratives. These are short stories based on personal observations and experiences. One method to capture these is via simple written postcards. Postcards from Work (Healthcare Edition) delves into these experiences. A sample of the cards is shown below ..read more

This article is a reproduction of an article published in HindSight magazine issue 32 in July 2021 on the theme of ‘The new reality’ (all issues available at SKYbrary) Healthcare is perhaps the most complex safety-critical sector, and the challenges have only increased throughout the COVID-19 pandemic. Increasingly, human and organisational factors have come under the spotlight. Manoj Kumar is a consultant general surgeon with a background also in safety, human factors, and training. In this conversation with Steven Shorrock, Manoj provides insights and perspectives on the ..read more

This article is a reproduction of an article published in HindSight magazine issue 28 in February 2019 on the theme of ‘Change’ (all issues available at SKYbrary) Some years ago, I was part of a major project involving a new ATC unit. This involved several changes – a whole new building in a new location, new technology, new positions, new procedures. I entered the project at a fairly late pre- operational stage. Everything was designed, built and mostly installed. The controllers were training for the change. Safety assessments, including human factors analysis, had a ..read more

This article is a reproduction of an article published in HindSight magazine issue 31 in December 2020 (all issues available at SKYbrary) On major projects, some surprises unfold slowly via ‘work-as-imagined solutioneering’. Based on observations in several industries, Steven Shorrock presents ten traps that we can all fall into. In the book The Wonderful Wizard of Oz, Dorothy is lost in a faraway land, and must travel the “road of yellow brick” to the Emerald City, where she will find Oz, the Great Wizard, who could help her get back to Kansas. Along the roa ..read more

Surprises in healthcare are common and can have lasting effects on clinicians. Steven Shorrock asked clinicians to reveal aspects of their experience with implications for learning. Image: U.S. Pacific Fleet When asked the following question, ten clinicians responded with a range of scenarios, each with lessons for us in how we think about and handle surprises. “Thinking about surprises in your work that left a trace in your mind, what have you learnt about handling surprises that you wished you had known earlier and that you would wish to pass onto others?” “As a result of regular s ..read more

This article is a reproduction of the Editorial published in HindSight magazine issue 34 in December 2022 (all issues available at SKYbrary) In safety-critical industries, surprises are rarely welcome. Aside from unexpected events we perceive as pleasant, like receiving a birthday cake, a thank-you note, or even a day when everything works as expected, surprises are not good things. The unwanted surprises that we may encounter, and how they are handled, differ depending on who we are and where we are in the system, whether in the control room, flight deck, surgical theatre, or boardroom. Image ..read more

HindSight is a magazine on human and organisational factors in operations. HindSight magazine is free and published twice a year, reaching tens of thousands of readers in aviation and other sectors worldwide. Published in December 2022, HindSight 34 focused on the theme of Handling Surprises: Tales of the Unexpected. You can download the full issue, and individual articles on SKYbrary. You will find an introduction to this Issue below, along with links to the magazine and the individual articles. Welcome to issue 34 of EUROCONTROL’s HindSight magazine, the magazine on human and organisational ..read more