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conditions.
Helmreich, R. L., & Merritt, A. C. (1998). Error management: a cultural universal in
aviation and medicine. In Helmreich (Ed.), Culture at work in aviation and medicine.
Brookfield, VT: Ashgate.
The authors discuss how professional, national, and organizational cultures intersect within
organizations and can be engineered towards a safety culture. This is done by examining the
interplay of cultures through behaviors at the sharp end of a system. Error management is
suggested as a necessary strategy to create a safety culture. More empirical data is needed to
ascertain an organization’s health and practices. Five precepts of error management are
acknowledged: Human error is inevitable in complex systems. Human performance has
limitations. Humans make more errors when performance limits are exceeded. Safety is a
universal value across cultures. And finally, high-risk organizations have a responsibility to
develop and maintain a safety culture.
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HFR British Airways Human Factors Reporting Programme. (1998). (NASA Aviation Data
Sources Resource Notebook).
The Human Factors Reporting Programme is a database that has four main purposes. The first is
to identify how and why a faulty plan was formulated. The second is to prevent a recurrence of
the circumstances or process. The third is to identify how well an organization supports the
activities of its flight crew. The fourth is to assure that the system does not assign blame to any
individual or agency. The database is coded into two main categories. One category is Crew
Actions. This category cover team skills (assertiveness, vigilance, workload management), errors
(action slips, memory lapses, mis-recognition), and aircraft handling (manual handling, system
handling). The other category is Influences. This category includes environmental factors
(airport facilities, ATC services, ergonomics), personal factors (complacency, distraction,
tiredness), organizational factors (commercial pressure, maintenance, training), and
informational factors (electronic checklists, information services, manuals). Each of these factors
can also be assigned in up to four ways. They can be positively/safety enhancing, negative/safety
degrading, first party or third party.
Hofmann, D. A. & Stetzer, A. (1996). A cross-level investigation of factors influencing
unsafe behaviors and accidents. Personnel Psychology, 49, 307-339.
A study was conducted to assess the role of organizational factors in the accident sequence in
chemical processing plants. Group process, safety climate, and intentions to approach other team
members engaged in unsafe acts were three group-level factors examined. Perceptions of role
overload was an individual-level factor that was also examined. Five hypotheses were made and
tested for significance. The first hypothesis was that individual-level perceptions of role overload
would be positively related to unsafe behaviors. This hypothesis was significant. The second was
that approach intentions would mediate the relationship between group process and unsafe
behaviors. This was not well supported. A third hypothesis was that group processes would be
negatively associated with actual accident rates. This was marginally supported. The fourth was
that safety climate would be negatively related to unsafe behaviors. This was significant. Finally
it was predicted that safety climate would be negatively related to actual accidents. This was
significant. A recommendation is made that safety practitioners engage in more systematic
organizational diagnosis.
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Hollnagel, E. (1993). Human reliability analysis: Context and control. San Diego, CA:
Academic Press.
The Contextual Control Model (COCOM) is a control model of cognition that has two important
aspects. The first has to do with the conditions under which a person changes from one mode to
another. The second concerns the characteristic performance in a given mode, which relates to
determining how actions are chosen and carried out. Four control modes are associated with the
model. These are scrambled, opportunistic, tactic and strategic. Scrambled control occurs when
the choice of next action is completely unpredictable or random. Opportunistic control is the case
where the next action is chosen from the current context alone. It is mainly based on the salient
features rather than intentions or goals. Tactical control refers to situations where a person’s
performance is based on some kind of planning and following a procedure or rule. Strategic
control means that the person is considering the global context. Two main control parameters are
used to describe how a person can change from one control mode to another. They are
　
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