Editorial: emerging issues in sociotechnical systems thinking and workplace safety.

The burden of on-the-job accidents and fatalities and the harm of associated human suffering continue to present an important challenge for safety researchers and practitioners. While significant improvements have been achieved in recent decades, the workplace accident rate remains unacceptably high. This has spurred interest in the development of novel research approaches, with particular interest in the systemic influences of social/organisational and technological factors. In response, the Hopkinton Conference on Sociotechnical Systems and Safety was organised to assess the current state of knowledge in the area and to identify research priorities. Over the course of several months prior to the conference, leading international experts drafted collaborative, state-of-the-art reviews covering various aspects of sociotechnical systems and safety. These papers, presented in this special issue, cover topics ranging from the identification of key concepts and definitions to sociotechnical characteristics of safe and unsafe organisations. This paper provides an overview of the conference and introduces key themes and topics. PRACTITIONER SUMMARY: Sociotechnical approaches to workplace safety are intended to draw practitioners' attention to the critical influence that systemic social/organisational and technological factors exert on safety-relevant outcomes. This paper introduces major themes addressed in the Hopkinton Conference within the context of current workplace safety research and practice challenges.

Sociotechnical approaches to workplace safety: Research needs and opportunities.

The sociotechnical systems perspective offers intriguing and potentially valuable insights into problems associated with workplace safety. While formal sociotechnical systems thinking originated in the 1950s, its application to the analysis and design of sustainable, safe working environments has not been fully developed. To that end, a Hopkinton Conference was organised to review and summarise the state of knowledge in the area and to identify research priorities. A group of 26 international experts produced collaborative articles for this special issue of Ergonomics, and each focused on examining a key conceptual, methodological and/or theoretical issue associated with sociotechnical systems and safety. In this concluding paper, we describe the major conference themes and recommendations. These are organised into six topic areas: (1) Concepts, definitions and frameworks, (2) defining research methodologies, (3) modelling and simulation, (4) communications and decision-making, (5) sociotechnical attributes of safe and unsafe systems and (6) potential future research directions for sociotechnical systems research. PRACTITIONER SUMMARY: Sociotechnical complexity, a characteristic of many contemporary work environments, presents potential safety risks that traditional approaches to workplace safety may not adequately address. In this paper, we summarise the investigations of a group of international researchers into questions associated with the application of sociotechnical systems thinking to improve worker safety.

Rasmussen's legacy: A paradigm change in engineering for safety.

This paper describes three applications of Rasmussen's idea to systems engineering practice. The first is the application of the abstraction hierarchy to engineering specifications, particularly requirements specification. The second is the use of Rasmussen's ideas in safety modeling and analysis to create a new, more powerful type of accident causation model that extends traditional models to better handle human-operated, software-intensive, sociotechnical systems. Because this new model has a formal, mathematical foundation built on systems theory (as was Rasmussen's original model), new modeling and analysis tools become possible. The third application is to engineering hazard analysis. Engineers have traditionally either omitted human from consideration in system hazard analysis or have treated them rather superficially, for example, that they behave randomly. Applying Rasmussen's model of human error to a powerful new hazard analysis technique allows human behavior to be included in engineering hazard analysis.

Application of systems and control theory-based hazard analysis to radiation oncology.

PURPOSE: Both humans and software are notoriously challenging to account for in traditional hazard analysis models. The purpose of this work is to investigate and demonstrate the application of a new, extended accident causality model, called systems theoretic accident model and processes (STAMP), to radiation oncology. Specifically, a hazard analysis technique based on STAMP, system-theoretic process analysis (STPA), is used to perform a hazard analysis. METHODS: The STPA procedure starts with the definition of high-level accidents for radiation oncology at the medical center and the hazards leading to those accidents. From there, the hierarchical safety control structure of the radiation oncology clinic is modeled, i.e., the controls that are used to prevent accidents and provide effective treatment. Using STPA, unsafe control actions (behaviors) are identified that can lead to the hazards as well as causal scenarios that can lead to the identified unsafe control. This information can be used to eliminate or mitigate potential hazards. The STPA procedure is demonstrated on a new online adaptive cranial radiosurgery procedure that omits the CT simulation step and uses CBCT for localization, planning, and surface imaging system during treatment. RESULTS: The STPA procedure generated a comprehensive set of causal scenarios that are traced back to system hazards and accidents. Ten control loops were created for the new SRS procedure, which covered the areas of hospital and department management, treatment design and delivery, and vendor service. Eighty three unsafe control actions were identified as well as 472 causal scenarios that could lead to those unsafe control actions. CONCLUSIONS: STPA provides a method for understanding the role of management decisions and hospital operations on system safety and generating process design requirements to prevent hazards and accidents. The interaction of people, hardware, and software is highlighted. The method of STPA produces results that can be used to improve safety and prevent accidents and warrants further investigation.

The systems approach to medicine: controversy and misconceptions.

The 'systems approach' to patient safety in healthcare has recently led to questions about its ethics and practical utility. In this viewpoint, we clarify the systems approach by examining two popular misunderstandings of it: (1) the systematisation and standardisation of practice, which reduces actor autonomy; (2) an approach that seeks explanations for success and failure outside of individual people. We argue that both giving people a procedure to follow and blaming the system when things go wrong misconstrue the systems approach.