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282 Chapter 10 Sociotechnical systems

height or speed, when an emergency occurs, and so on. For new systems, these oper-
ational processes have to be defined and documented during the system development
process. Operators may have to be trained and other work processes adapted to make
effective use of the new system. Undetected problems may arise at this stage because
the system specification may contain errors or omissions. Although the system may
perform to specification, its functions may not meet the real operational needs.
Consequently, the operators may not use the system as its designers intended.
The key benefit of having system operators is that people have a unique capabil-
ity of being able to respond effectively to unexpected situations, even when they
have never had direct experience of these situations. Therefore, when things go
wrong, the operators can often recover the situation although this may sometimes
mean that the defined process is violated. Operators also use their local knowledge to
adapt and improve processes. Normally, the actual operational processes are differ-
ent from those anticipated by the system designers.
Consequently, you should design operational processes to be flexible and adapt-
able. The operational processes should not be too constraining, they should not
require operations to be done in a particular order, and the system software should
not rely on a specific process being followed. Operators usually improve the process
because they know what does and does not work in a real situation.
A problem that may only emerge after the system goes into operation is the oper-
ation of the new system alongside existing systems. There may be physical problems
of incompatibility or it may be difficult to transfer data from one system to another.
More subtle problems might arise because different systems have different user
interfaces. Introducing a new system may increase the operator error rate, as the
operators use user interface commands for the wrong system.

10.5.1 Human error
I suggested earlier in the chapter that non-determinism was an important issue in
sociotechnical systems and that one reason for this is that the people in the system do
not always behave in the same way. Sometimes they make mistakes in using the sys-
tem and this has the potential to cause system failure. For example, an operator may
forget to record that some action has been taken so that another operator (erro-
neously) repeats that action. If the action is to debit or credit a bank account, say,
then a system failure occurs as the amount in the account is then incorrect.
As Reason discusses (2000) human errors will always occur and there are two
ways to view the problem of human error:

1. The person approach. Errors are considered to be the responsibility of the indi-
vidual and ‘unsafe acts’ (such as an operator failing to engage a safety barrier)
are a consequence of individual carelessness or reckless behavior. People who
adopt this approach believe that human errors can be reduced by threats of dis-
ciplinary action, more stringent procedures, retraining, etc. Their view is that
the error is the fault of the individual responsible for making the mistake.