（建筑工程管理）人因工程学

建筑工程管理人因工程学人因工程学的组织结构作者：查尔斯佩罗人因工程学关心的是设备设计和操作员工的生理和心理特征是否壹致的问题。人因工程学给设计工程师建议，可是其组织内容又会局限他们的影响和想法。这篇论文讨论的内容解释了为什么军队和工业的高层人事管理不同于好的人因设计，展示了社会机构是如何喜爱选择集中权威和降低那些做出不合理错误归因的操作员工技术要求的工艺。我们需要探索处于良好状态的认知地图和心智模式的设备和系统设计，以及技术社会的结构模式。介绍15的军队武器不能瞄准甚至有时不能开火，如此昂贵的精密的军用飞机很少能飞过它们或向它们武器开火，船只碰撞而官员们于期待壹个科技奇迹即能解决人和机器问题的壹个防冲突雷达设置。这篇文章讲述了壹个尚未探索的方面—人和机器的问题，即通过分析这俩者的组织结构内容及联系，那就是，其组织结构如何影响设备的设计，以及如何运用新的设备反应其组织结构。设备设计者有责任采取运营者和维修人员的特点来考虑他们的设计，这才是真正的人因工程师（HFE，第二次世界大战前可能只有壹小部分人是，但当下的数字叫人类工程学。HFEsHFEs对社会和组织环境中的作用。鉴于很多恐怖的事情比如设备的设计不良难以适应人类的能力，我确保第壹个任务是参加操作员的生理和心理的特点，但更为广泛HFHFEs么小，且建议采取措施纠正这种情况。（佩罗，1984。设计问题加上材料，物理革命，它已成为可能的需求，如更快的速度，力量，可操作性，能够于比以往更多的敌意的环境中（外空，风暴工作于从军事和工业设备，电子产品更高的性能水平海，雾方向机场）或者接近人口密度，瞬时通讯于很远的距更高的系统性能已经达到了三种方式改变运营者的作用：要求更高的技能和服务（高压，高负荷工作，更复杂的任务，需要高认知特点的商船甲板人员，宇航员的作用，飞行员和航空运输于他们参观的职责，核，化学工厂运营者于紧急情况下的关键阶段，以及像战斗机飞行员和坦克指挥官壹般。被动监测于长的特点，他们的巡演，敌侦察系统例行飞行阶段和海洋船员和核武器和化学工厂运营者，如区分了静态的阴极射线管敌方潜艇的轨道，机载监视系统。所有这些系统均具有于运营商的角色，自动化装置的例子，第三改变完全绕过运营商。这些变化的系统中，导致于运营商及其设备之间的界面设计问题，于维修间的人监测模式鼓励非技术化，单调和低系统的理解，导致精神低落，产量低，缺乏技能和应付意外紧急情况或甚至变化的系统状态。运营者进行设计，通过自动化控制系统，于紧急情况下或不正常的条件下减少他们的系统理解和干预能力。于紧急情况下干预或当不正常的条件下，设备复杂的事实。它的维修保养往往成小包装，无法使空间展开。这种先进的系统的高费用的建设和营运可减少训练时间，增加了失败的代价。有时是很难让操作员使用新设备去提高系统性能，因为他们不信任它们，发现它们也难以操作，或者觉得他们使之更难以达到的性能指标。海军飞行员有抬头显于他们的挡风玻璃上，有明确的塑料预测他们认为实际的甲板上，从而于飞机配置该计算机的方式确定这些条件是最好的。虽然减轻了工作量，壹些飞行员缺乏信心，担心这会导致它的场合发生故障时所需要的技能衰退，且认为他们的经验（1980船用甲板人员忽视出于同样的原因复杂的防撞设备，仍因为它实际上增加了工作量和分散他们的沟通及1981产目标（佩偌,1984。因此，系统设计了关联的决定和对运营者的过分要求，单HFE的任务是提供意见，以设计工程师如何设计的设备和系统，从而最大限度地减少这些问题。（壹军事卷是少数于100页的长度，例如，交换机均应该右转，插座应设计所以，错误的插头（2际设计和提出改革建议;（3）或可能实际上和工程师，设计演变。的角度见，限制条件，这是孤🖂HFE），设计工程师关切体位限制（范围，强度，视觉和运动灵敏度，响应时间，认知能力和记忆体限制，以及工作负载的能力。虽然设计者往往不了解这些限制运营和设营者的职能。此外，它是明显的，许多文献和实地观察，HFEs面的认识，于他们的组织以及运营者的工作可能说明为什么他们的影响力是如此微不足道。HFE师，这反过来又影响了设备，但如何将这些全部是该组织所影响的社会结构和影111社会结构。这种关系是最为关联的被忽视的问题：为什么于大多数军事和许多工业组织的人的因素，原则是这样的工程。结构的关联方面将要讨论的是高层管理以及组织文化的某些方面。高层管理人员及设计最终，于设计上忽视居所资助计划于工程中可能于于他们消费这些设计中，无论是谁，有设计了他们的房子或出示指定谁为供应商。壹个组织的分析师将放于解释没有什么价值，设计工程师忽略或忽视他们的居所资助计划，因为他们不知道的，是他们的蔑视，不想再打扰他们，或以某种方式或其他他们无法欣赏。这些可能是近似的解释，因为壹些文献提示（梅斯特和法尔，19671971年仰体系和管理，顶部。最高管理层能够，如果愿意，告知工程设计高频的存于，原则的信息，能够要求这些原则加以利用，且能结构的奖励制度，鼓励设计师，它考虑到了这些原则。高频工程的原则可能不是十分便利，有说服力的，或容易使用，但我怀疑相对较少的努力要避免使用不同的尺度上不同的控制面板布局为俩个相同的表盘和子系统或相邻俩个类似的，甚至相同的子系统，或放于几乎是无法避免的安全装置中的关键领域。错误的设计，很多的例子（塞米纳拉，冈萨1976（1980100系统中使用的约（1982，研究了过热船只，且于海军研究咨询委员会的居所资助计划的方案（1980。你也能够谈于车库机械师。），其后果是由运营者承担。灾难缺乏良好的宣传，工计不良，是由大家来判断别人是自私。即使于设计知识贫困变得普遍，作为核控制室，奥拉斯证明新军步枪拜斯维修问（1981们的成本相对较低的事业。奖励工作的规范组织的领导人就于于谁决定以外的地方于这些设备的有效性能。上诉的权力的速度，机动性和轻松胜出之上考虑易维护和操作方便的选择设计，仍有壹些内部的顾问人员谁能够提醒到这壹点。行政奖励是选择最新和最先进的设计，即使它们没有经过测试。几年后，当系统交付及运营，行政机关已经提出，如果他或她几乎是于壹个军事组织，它强制轮换的俩，三年，或者如果没有，行政机关能够归咎于技术，使设计的承诺对目前复杂的。高风险，高科技系统已经和事后的小地方的历史，奖励必须由目前的活动。无论是高层管理人员或不忽略高频设计，其后果相当贫困的措施取决于对较大型系统，其中存于的组织。阿考虑对比的错误，避免航空运输系统和错误诱导的海上运输系统将首先说明如何管理的类别将难以忽视高频，而那些于第二次会发现很容易，甚至有利可图的航空运输制度，绩效管理制度的影响，通过奖励的利润情况和性能故障🖂即影响利润和声誉。故障接收媒体报道和彻底的调查和公开的利益不同的当事方和（管理机构，联邦航空管理局，壹个独🖂的安全委员会，国家运输安全委员会和飞行员工会），以及未能确定的原因有法律和保险的后果。该系统的用户能够退出，且使用其他系统（航空公司）或其他运输方式于壹定程）是相对简单的，可用，适合小规模的维修人员和小系统业者（俩个或三个船员，俩个或三个空中交通管制员，壹个小维修）。合理兼容独🖂人士（制造商，航空公司，工会，管理机构，以及空中交通控制系统）作为相互制衡的航空公司和利益，乘客和控制器（例如，减少挤塞节省燃料，时间空气，降低互动的复杂性。（那么，军等系统，他们缺乏最上面的海洋运输系统是国际性的，但当事国利益相互矛盾，因此壹些规定是有效的。经济损失是很少注意吸收和传递到最终消费者，和人类的损失限于最初的人员和船员。环境是非常敌对，自然灾害和相互作用船舶危险是间断性的，比较难以预测，分布于长的时间跨度，限制了学习，经验和常规化，有效的保障。生产高，竞争压力相对不受管制。事故原因的分析是困难和阻碍国家利益，弱弱的监管机构和工会，占沉没的船只和船员，不可靠的，重建缺乏事故监测数据。加强（集中系统的命令于壹个日益互动，于下面讨论。该系统对比航空公司和海洋是佩罗阐述（1984。因此，该组织的性质有壹个HFS影响高层管理人员的注意，以支付，这转变的工程师分析，从设计到高层管理人员和服务的角度把这个问题：对于某些系统，良好的人力因素的设计是不很关联的高层管理人员，但它肯定是飞行员和锅炉操作员于军事和航海。壹个隐含的观点是，HFEs们的努力宣传他们的积极支持。这种宣传会，动员别人把管理人员的压力于最前面。这将是很难做到的国防合同和海洋的设计，但它不会是不可能的。例如，根（1982（了更大的效益）的培训走向桥的团队，所设计的设备，正于反映了负责控制人员于团队合作的潜力，而不是集中。或许，这将是不可能作出回避制度的结构性变革，从而使海洋运输壹明显的错误，只是因为它可能无法使航空运输系统的错误诱导系统。然而，更能够做和海洋运输，均是考虑到组织因素。（1）（2）自己设计的工程师谁写的规格（或于某些个案设计和建造系统）的设计的重要性良好的高频？组织理论家关注这个社会的组织结构会回答：“当然。”他们不会，可是，所有的经理均认为，这样做是为了输出居所资助计划予以考虑，任何超过他们能够命令努力工作，忠诚，或质量。事实上，书面命令只造福，是提供法律支持纪律应该是方便，甚至是必要的。理论家会，而是强调不唐突的控制。例如，高层管理人员能够控制的设计人员使用的处所，而不是试图控制他们的行为直接（佩罗，1977）如下：确保HFEs于身体附近的设计师，使他们能够建🖂互动和非正式的个人和团体的债券。HF训，从而提高了HFE的地位。HFE撰写和散发HFEs方案的贡献。切不发送信号）。1。TheOrganizationalContextofHumanFactorsEngineeringAuthor(s):CharlesPerrowHumanfactorsengineeringconcernsthedesignofequip-mentinaccordancewiththementalandphysicalcharac-teristicsofoperators.Humanfactorsengineersadvisede-signengineers,buttheorganizationalcontextlimitstheirinfluenceandrestrictstheirperspective.Thediscussionoforganizationalcontextinthispaperexplainswhymilitaryandindustrialtopmanagementpersonnelareindifferenttogoodhumanfactorsdesignandshowshowthesocialstructurefavorsthechoiceoftechnologiesthatcentralizeauthorityanddeskilloperatorsandhowitencouragesunwarrantedattributionsofoperatorerror.Theroleofequipmentandsystemdesigninshapingcognitivemapsandmentalmodelsisexplored,andthetechnology-socialstructureparadigmisquestioned.INTRODUCTIONSomerecentdisastersandneardisastersinhigh-technologysystemshavegeneratedincreasedconcernabouttheinteractionofoperatorsandequipmentincomplexmilitaryandindustrialsystems.Fifteen-footbanksofidenticalswitcheswithsmallcodenumbersunderneaththeminnuclearpowerplants,sophisticatedarmyweaponsthatpersonnelcannotaimorevenfireattimes,sophisticatedmilitaryaircraftthataresoexpensivetooperatethatpilotscanrarelyflythemorfiretheirweapons,shipsthatcollidewhiletheofficersareobservingoneanotheronanticollisionradardevicesallsuggestanoperator-machineproblemintheworldoftechnologicalmarvels.Thisessayaddressesanunexploredaspectoftheoperator-machineproblembyanalyzingtheorganizationalcontextthatstructurestherelationshipbetweenthetwo;thatis,howorganizationalstructureaffectsthedesignofequipment,andhownewequipmentreproducestheorganizationalstructure.Responsibilityforseeingthatequipmentdesignerstakethecharacteristicsofoperatorsandmaintenancepeopleintoac-countintheirdesignsisformalizedinthepositionofthehumanfactorsengineer(HFE),amemberofasmalldisciplinethatemergedafterWorldWar11andthatnownumbersperhaps5,000engineersandengineeringpsychologists.Thedisciplineisalsoreferredtoashumanengineering,andinEurope,asergonomics.HFEsattempttobroadenthepurviewofthedesignengineerbyadvisinghimorheronthephysicalandbiologicalcharacteristicsofoperatorsandmaintenancepersonnel.Iwill,inturn,attempttobroadenthepurviewofHFEsbyadvisingthemonthesocialandorganizationalcontextinwhichequipmentoperatorsfunction.Giventhemanyhorrorstoriesofequipmentthatispoorlydesignedtofithumancapabilities,Iamsurethatthefirstpriorityistoattendtophysicalandbiologicalcharacteristicsofoperators,yetthemoreextendedconcernofferedhereisalsoimportant,anditsuggestsinsightsastowhyHFrecommendationsareneglectedandthenumberofHFEsissosmall,andsuggestsstepstoremedythissituation.Itwillalsobearguedthatorganizationaltheorycanbenefitfromanexaminationoftherelationshipbetweenequipmentdesignandorganizationalstructure,amuchneglectedtopicexceptinsomehistoricalstudies.Ratherthantechnologydeterminingorganizationalstructure,itwouldappearthatmachinesandequipmentaredesignedsothattheyreinforceexistingstructuresandreproducethesestructuresinnewsettings.Organizationstructuresaswellashuman-machineinterfacesmaycontributetoaccidents,amatterofconcernwherecatastrophicpotentialexists,asinsomanyofthemilitaryandindustrialsystemsconsideredhere.Someofthepointsofthisessayarediscussedinmoredetailelsewhere(Perrow,1984).THEDESIGNPROBLEMWithrevolutionsinmaterials,physics,andelectronicsithasbecomepossibletodemandhigherperformancelevelsfrommilitaryandindustrialsystems,suchasmorespeed,power,maneuverability,theabilitytooperateinever-more-hostileenvironments(outerspace,stormsatsea,fog-boundairports)circlosertopopulationconcentrations,instantaneouscommunicationsovergreatdistances,andcreaturecomfortstocrewsorpassengers,andfinally,tomeettheendlessdemandformorecapacityoroutput.Highersystemperformancehasbeenachievedbyalteringtheoperator'sroleinthreeways:demandinghigherskillsandlevelsofperformance,reducingoperatingtaskstopassivemonitoring,orautomatingfunctions(inengineeringvernacularthisis"removingthemanfromtheloop").Highpressure,highworkload,andmoretasksrequiringhighcognitivecomplexitycharacterizetheroleofmerchantmarinedeckofficers,astronauts,andairtransportpilotsincriticalphasesoftheirtourofduty,nuclearandchemicalplantoperatorsduringemergencies,andfighterpilotsandtankcommandersgenerally.Passivemonitoringcharacterizesflightandmarinecrewsandnuclearandchemicalplantoperatorsduringlong,routinephasesoftheirtour,enemydetectionsystemssuchasdistinguishingthetrackofenemysubmarinesfromthestaticoncathoderaytubes,andairbornsurveillancesystems.Allthesesystemshaveexamplesofthethirdalterationintheoperator'srole,automateddevicesthatbypasstheoperatorentirely.Thesechangesinsystemshaveledtoproblemsinthedesignoftheinterfacebetweenoperatorsandtheirequipment,andalsoproblemsintheinterfacebetweenmaintenancepersonnelandtheequipment.Thehigh-demandmodethreatenstoexceedthephysicalandbiologicalcapacitiesofoperators;thepassive-monitoringmodeencouragesdeskilling,tedium,andlowsystemcomprehension,leadingtolowmorale,lowoutput,andlackofskillstocopewithemergenciesorevenunexpectedvariationsinsystemstate.Designingoperatorsoutofthecontrolsystemthroughautomationreducestheirsystemcomprehensionandabilitytointerveneinemergenciesorwhenconditionsareabnormal.Thecomplexityoftheequipmentandthefactthatitisoftenpackedintosmall,inaccessiblespacesmakesmaintenancedifficult.Thehighexpenseofbuildingandoperatingsophisticatedsystemsreducesavailabletrainingtimeandincreasestheexpenseoffailures.Itissometimesdifficulttogetoperatorstousenewdevicesdesignedtoincreasesystemperformancebecausetheydonottrustthem,findthemtoodifficulttooperate,orfeelthattheymakeitmoredifficulttoreachperformancetargets.Navalpilotshaveaheads-updisplay(HUD)thatgeneratesacomputerimageoftheaircraftdecktheyaretolandon;theyaretomatchtheimage,projectedonclearplasticintheirwindscreen,withtheirviewoftheactualdeck,thusconfiguringtheaircraftinthemannerthatthecomputerdeterminesisbestfortheseconditions.Whileiteasestheworkload,somepilotslackconfidenceinit,fearitwillleadtoadecayofskillsneededfortheoccasionswhenitmalfunctions,andbelievethattheirexperienceisabetterguidethantheprogramwrittenbyengineers(Newman,1980).Marinedeckofficersignoresophisticatedcollision-avoidanceequipmentforsimilarreasons,andalsobecauseitactuallyincreasesworkloadanddistractsthemfromcommunicationandothertasks(Gardenier,1981).Nuclearplantoperatorsdisableautomaticsystemsandsafetydevicesinordertomeetproductiongoals(Perrow,1984).Thus,systemdesigndecisionshavebeenassociatedwithproblemsofexcessivedemandsonoperators,tediumandwithdrawal,lackofsystemcomprehension,maintenanceproblems,andunauthorizeddeviationsfrommandatedpractices.ItisthetaskoftheHFEtoadvisethedesignengineersastohowtodesignequipmentandsystemsthatwillminimizetheseproblems.Humanfactorsengineersmay(1)drawuplistsofrequirementsthatdesignengineersareexpectedtoabideby(onemilitaryvolumeisafewhundredpagesinlengthandrequires,forexample,thatswitchesshouldallturntotherightandsocketsshouldbedesignedsothatthewrongplugcannotbeinserted,andindicateshowfar90percentoftheexpecteduserscanreachtoflickaswitch);(2)reviewactualdesignsandrecommendchanges;(3)ormayactuallyworkwithengineersasdesignsareevolving.ThebackgroundofHFEsisgenerallyengineeringpsychology.Whileappropriatefortheirbasicwork,itpromotesadistinctiveperspective,thatoftheisolatedhuman,subjectonlytobiologicallimitations.TheHFEbringstothedesignengineerconcernsaboutanthropometriclimits(reach,strength,etc.),visualandmotorsensitivity,responsetime,cognitivecapacityandmemorylimits,andwork-loadcapacity.Whiledesignersareoftenunawareoftheselimitsanddesignequipmentthatcannotbereasonablyoperated,thereisinsufficientawarenessonthepartofbothHFEsanddesignengineersoftheorganizationalcontextinwhichtheoperatorfunctions.Furthermore,itisapparentfromtheliteratureandmanyfieldobservationsthatHFEshaveagreatdealoftroubleinfluencingdesigners,evenwithrespecttothebiologicallimitsofoperators;HFEslackinfluenceinmostmilitaryandmanyindustrialorganizations.Anawarenessoftheorganizationalcontextinwhichtheyaswellasoperatorsworkmightindicatewhytheirinfluenceissoslight.TheorganizationalcontextofhumanfactorsshouldincludenotonlythelimitedsequenceoftheHFEinfluencingthedesignengineer,whichinturninfluencestheequipmenttheoperatoruses,buthowalloftheseareinfluencedbythesocialstructureoftheorganizationandinfluenceitinturn.Figure1presentsthemodelthatwillguidetherestofthispaper.ThearrowsofFigure1indicatethebasicdirectionsofinfluencethatwillbediscussed.Arrow1indicatestheinfluenceofthesocialstructureonthedesignengineer.Thisrelationshipismostpertinenttothequestionofwhy,inmostmilitaryandmanyindustrialorganizations,theprinciplesofhumanfactorsengineeringaresoneglected.Therelevantaspectsofthestructuretobediscussedaretopmanagementgoalsandperspectives,therewardstructureoftheorganization,insulationofdesignengineersfromtheconsequencesoftheirdecision,andsomeaspectsoforganizationalculture.TOPMANAGEMENTANDDESIGNUltimately,theneglectofHFsinengineeringdesignsprobablyrestswiththeconsumerofthesedesigns,whoeitherhasthedesignsmadein-houseorspecifiesthemforvendorswhoproducethem.AnorganizationalanalystwouldplacelittlevalueonexplanationsthatdesignengineersignoreorneglectHFEsbecausetheyareunawareofthem,arecontemptuousofthem,donotwanttobebotheredwiththem,oraresomehoworotherincapableofappreciatingthem.Thesemightbeproximateexplanations,assomeoftheliteraturehints(MeisterandFarr,1967;Meister,1971),buttheorganizationalanalystseesman-agersandprofessionalsasrespondingtotherewardsandsanctions,andtheprevailingbeliefsystems,oftopmanagement.Topmanagementcan,ifitwishes,informdesignersoftheexistenceofinformationabouttheprinciplesofHFengineering,canrequirethattheseprinciplesbeutilized,andcanstructuretherewardsystemsothatitencouragesdesignerstotaketheseprinciplesintoaccount.TheprinciplesofHFengineeringmaynotbeveryaccessible,convincing,oreasytouse,butIsuspectthatcomparativelylittleeffortisrequiredtoavoidusingdifferentcontrolpanellayoutsfortwoidenticalandadjacentsubsystemsordialswithdifferentscalesontwosimilarorevenidenticalsubsystems,ortoavoidplacingkeysafetydevicesinareasthatarevirtuallyinaccessible.ManyexamplesoffaultydesignssuchasthesearegivenintheextensiveLockheedstudyofcontrolroomdesigninnuclearplants(Seminara,Gonzales,andParsons,1976),theEssexstudycomparingtheThreeMileIslandplantwithsomeothers(Maloneetal.,1980),thenavystudyofthesuperheated-steamsystemusedinabout100navalvessels(Williamsetal.,1982),andintheNavalResearchAdvisoryCommittee(1980)reportonHFEs.Onecanalsotalktoagaragemechanic.Ratherthanblamethedesignengineer,theorganizationalanalystwouldask:whobearstheconsequenceofpoordesign?Inmosthigh-technologysystemsthatarenotsolddirectlytoalargenumberoffinalcustomers(exceptformass-produceditemssuchaspersonalcomputers,cameras,ortelevisionsets),theconsequencesarebornebytheoperators.Shortofawell-publicizedcatastrophe,theengineerwillprobablyneverknowtheconsequencesofhisorherdesign,andtopmanagementwillonlyhearofitfaintlyandperhapsnotuntilthenextprojectisalreadyunderconstruction.Theydonothearbecausethecostsarebornebythosewhomustmakethesystemworkonadailybasis,andtheoperators'argumentthatitispoorlydesignedisjudgedbyeveryoneelsetobeself-serving.Evenwhenknowledgeofpoordesignbecomeswidespread,aswithnuclearcontrolrooms,orasevidencedbythemaintenanceproblemswithhigh-performancemilitaryaircraftortheunreliabilityofanewarmyrifle(Fallows,1981),topmanagersmayjudgethecoststothemandtheircareerstoberelativelylow.Therewardsoperatingfortheorganizationalleaderswhodecideonthespecificationslieelsewherethanintheeffectiveperformanceofsuchequipment.Theappealsofspeed,power,andmaneuverabilityeasilywinoutoverconsiderationsofeasymaintenanceandeaseofoperationinchoosingdesigns,andtherearefewin-houseadviserswhocanalerttheexecutivestothis.Theexecutiveisrewardedforchoosingthelatestandmostsophisticateddesigns,eventhoughtheyareuntested.Someyearslater,whenthesystemsaredeliveredandoperated,theexecutivewillhavemovedonifheorsheisinamilitaryorganization,whichhasnearlymandatoryrotationsoftwoorthreeyears,orifnot,theexecutivecanblamethetechnologyandmakepromisesaboutthecurrentsophisticateddesign.High-risk,high-technologysystemshavelittleplaceforhistoryandhindsight;rewardsmustcomefrompresentactivity.WhethertopmanagementdoesordoesnotignoretheconsequencesofpoorHFdesignsdependsinconsiderablemeasureonthelargersysteminwhichtheorganizationexists.Acontrastbetweentheerror-avoidingairtransportsystemandtheerror-inducingmarinetransportsystemwillillustratehowmanagementinthefirstcategorywillfindithardtoignoreHFconsiderations,whilethoseinthesecondwillfinditeasyandevenprofitableIntheairtransportsystem,performanceaffectsmanagementrewardsthroughtheprofitstatusofthesystem,andperformancefailuresaffectprofitsandreputationimmediately.Failuresreceivemediacoverageandarethoroughlyandopenlyinvestigatedbypartieswithdifferinginterests(aregulatoryagency-FederalAviationAdministration,anindependentsafetyboard-theNationalTransportationSafetyBoard,andthepilots'union),andthedeterminationofthecauseoffailurehaslegalandinsuranceconsequences.Usersofthesystemcanexitfromitanduseothersystems(airlines)orothertransportationmodestosomedegree.Technological"fixes"(technologythatcompensatesfor,repairs,orreplacesfaultytechnology)arerelativelysimple,available,andfitthesmallsizeofsystemoperators(acrewoftwoorthree,twoorthreeairtrafficcontrollers,asmallmaintenancecrew).Independentparties(manufacturers,airlines,unions,regulatoryagencies,andtheairtrafficcontrolsystem)serveaschecksoneachother,andtheinterestsofairlines,passengers,andcontrollersarereasonablycompatible(e.g.,lesscongestionsavesfuel,timeintheair,andreducesinteractivecomplexity).Incontrast,themarinetransportsystemiserrorinducing.(Soaremilitarysystems;theylackmostoftheabovechecks.)Themarinetransportsystemisinternational,butthenationsinvolvedhaveconflictinginterests;thusfewregulationsare5251ASQ,December1983effective.Economiclossesareabsorbedwithlittlenoticeandpassedontothefinalconsumer,andhumanlossesareinitiallyrestrictedtotheofficersandcrew.Theenvironmentisextremelyhostile,andnaturalhazardsandthehazardousinteractionsofshipsareintermittent,relativelyunpredictable,andspreadoverlongtimespans,limitinglearning,experience,androutinized,efficientsafeguards.Productionpressuresarehighandcompetitioniscomparativelyunregulated.Analysisofcausesofaccidentsisdifficultandimpededbynationalinterests,weakregulatoryagenciesandweakunions,thesinkingofthevesselandthecrew,unreliableaccounts,andlackofmonitoringdataforaccidentreconstruction.Technologicalfixesreinforceaninappropriateauthoritystructure(centralizingcommandinanincreasinglyinteractivesystem,discussedbelow).ThecontrastbetweenairlineandmarinesystemsiselaboratedinPerrow(1984).Thus,thenatureoftheorganizationhasanimpactontheattentionthattopmanagementpaystoHFEs;thisshiftstheanalysisfromdesignengineerstotopmanagementandservestoplacetheprobleminperspective:Forsomesystems,goodhumanfactorsdesignissimplynotveryrelevanttotopmanagement,thoughitcertainlyistopilotsandboileroperatorsinthemilitaryandtomariners.OneimplicationofthisperspectiveisthatHFEswouldbemorelikelytogetsupportiftheypublicizedthelackofsupportfortheireffortsaggressively.Suchpublicitywouldhavetomobilizeotherstoputpressureontopmanagements.Thatwouldbehardtodoindefensecontractingandmarinedesigns,butitwouldnotbeimpossible.Forexample,accordingtoGaffney(1982),theEuropeanship-pingcommunity(moreofacommunitythanthoseintheotherpartsoftheworld,whichmayaccountforitsgreatereffectiveness)hasmovedtowardbridge-teamtraining,andtheequipmentthatisbeingdesignedreflectsteamworkpotentialsratherthancentralizedcontrolbytheofficerincharge.Itwouldprobablybeimpossibletomakethestructuralchangesneededtomakemarinetransportamarkedlyerror-avoidingsystem,justasitwouldprobablybeimpossibletomaketheairtransportsystemanerror-inducingsystem.Nevertheless,morecouldbedonewithmarinetransport,wereorganizationalfactorstakenintoaccount.Eveniftopmanagerswereconvincedthatatlea