（建筑工程管理）人因工程學

建筑工程管理人因工程學人因工程學的組織結(jié)構(gòu)作者：查爾斯佩羅人因工程學關(guān)心的是設備設計和操作員工的生理和心理特征是否壹致的問題。人因工程學給設計工程師建議，可是其組織內(nèi)容又會局限他們的影響和想法。這篇論文討論的內(nèi)容解釋了為什么軍隊和工業(yè)的高層人事管理不同于好的人因設計，展示了社會機構(gòu)是如何喜愛選擇集中權(quán)威和降低那些做出不合理錯誤歸因的操作員工技術(shù)要求的工藝。我們需要探索處于良好狀態(tài)的認知地圖和心智模式的設備和系統(tǒng)設計，以及技術(shù)社會的結(jié)構(gòu)模式。介紹15的軍隊武器不能瞄準甚至有時不能開火，如此昂貴的精密的軍用飛機很少能飛過它們或向它們武器開火，船只碰撞而官員們于期待壹個科技奇跡即能解決人和機器問題的壹個防沖突雷達設置。這篇文章講述了壹個尚未探索的方面—人和機器的問題，即通過分析這倆者的組織結(jié)構(gòu)內(nèi)容及聯(lián)系，那就是，其組織結(jié)構(gòu)如何影響設備的設計，以及如何運用新的設備反應其組織結(jié)構(gòu)。設備設計者有責任采取運營者和維修人員的特點來考慮他們的設計，這才是真正的人因工程師（HFE，第二次世界大戰(zhàn)前可能只有壹小部分人是，但當下的數(shù)字叫人類工程學。HFEsHFEs對社會和組織環(huán)境中的作用。鑒于很多恐怖的事情比如設備的設計不良難以適應人類的能力，我確保第壹個任務是參加操作員的生理和心理的特點，但更為廣泛HFHFEs么小，且建議采取措施糾正這種情況。（佩羅，1984。設計問題加上材料，物理革命，它已成為可能的需求，如更快的速度，力量，可操作性，能夠于比以往更多的敵意的環(huán)境中（外空，風暴工作于從軍事和工業(yè)設備，電子產(chǎn)品更高的性能水平海，霧方向機場）或者接近人口密度，瞬時通訊于很遠的距更高的系統(tǒng)性能已經(jīng)達到了三種方式改變運營者的作用：要求更高的技能和服務（高壓，高負荷工作，更復雜的任務，需要高認知特點的商船甲板人員，宇航員的作用，飛行員和航空運輸于他們參觀的職責，核，化學工廠運營者于緊急情況下的關(guān)鍵階段，以及像戰(zhàn)斗機飛行員和坦克指揮官壹般。被動監(jiān)測于長的特點，他們的巡演，敵偵察系統(tǒng)例行飛行階段和海洋船員和核武器和化學工廠運營者，如區(qū)分了靜態(tài)的陰極射線管敵方潛艇的軌道，機載監(jiān)視系統(tǒng)。所有這些系統(tǒng)均具有于運營商的角色，自動化裝置的例子，第三改變完全繞過運營商。這些變化的系統(tǒng)中，導致于運營商及其設備之間的界面設計問題，于維修間的人監(jiān)測模式鼓勵非技術(shù)化，單調(diào)和低系統(tǒng)的理解，導致精神低落，產(chǎn)量低，缺乏技能和應付意外緊急情況或甚至變化的系統(tǒng)狀態(tài)。運營者進行設計，通過自動化控制系統(tǒng)，于緊急情況下或不正常的條件下減少他們的系統(tǒng)理解和干預能力。于緊急情況下干預或當不正常的條件下，設備復雜的事實。它的維修保養(yǎng)往往成小包裝，無法使空間展開。這種先進的系統(tǒng)的高費用的建設和營運可減少訓練時間，增加了失敗的代價。有時是很難讓操作員使用新設備去提高系統(tǒng)性能，因為他們不信任它們，發(fā)現(xiàn)它們也難以操作，或者覺得他們使之更難以達到的性能指標。海軍飛行員有抬頭顯于他們的擋風玻璃上，有明確的塑料預測他們認為實際的甲板上，從而于飛機配置該計算機的方式確定這些條件是最好的。雖然減輕了工作量，壹些飛行員缺乏信心，擔心這會導致它的場合發(fā)生故障時所需要的技能衰退，且認為他們的經(jīng)驗（1980船用甲板人員忽視出于同樣的原因復雜的防撞設備，仍因為它實際上增加了工作量和分散他們的溝通及1981產(chǎn)目標（佩偌,1984。因此，系統(tǒng)設計了關(guān)聯(lián)的決定和對運營者的過分要求，單HFE的任務是提供意見，以設計工程師如何設計的設備和系統(tǒng)，從而最大限度地減少這些問題。（壹軍事卷是少數(shù)于100頁的長度，例如，交換機均應該右轉(zhuǎn)，插座應設計所以，錯誤的插頭（2際設計和提出改革建議;（3）或可能實際上和工程師，設計演變。的角度見，限制條件，這是孤??HFE），設計工程師關(guān)切體位限制（范圍，強度，視覺和運動靈敏度，響應時間，認知能力和記憶體限制，以及工作負載的能力。雖然設計者往往不了解這些限制運營和設營者的職能。此外，它是明顯的，許多文獻和實地觀察，HFEs面的認識，于他們的組織以及運營者的工作可能說明為什么他們的影響力是如此微不足道。HFE師，這反過來又影響了設備，但如何將這些全部是該組織所影響的社會結(jié)構(gòu)和影111社會結(jié)構(gòu)。這種關(guān)系是最為關(guān)聯(lián)的被忽視的問題：為什么于大多數(shù)軍事和許多工業(yè)組織的人的因素，原則是這樣的工程。結(jié)構(gòu)的關(guān)聯(lián)方面將要討論的是高層管理以及組織文化的某些方面。高層管理人員及設計最終，于設計上忽視居所資助計劃于工程中可能于于他們消費這些設計中，無論是誰，有設計了他們的房子或出示指定誰為供應商。壹個組織的分析師將放于解釋沒有什么價值，設計工程師忽略或忽視他們的居所資助計劃，因為他們不知道的，是他們的蔑視，不想再打擾他們，或以某種方式或其他他們無法欣賞。這些可能是近似的解釋，因為壹些文獻提示（梅斯特和法爾，19671971年仰體系和管理，頂部。最高管理層能夠，如果愿意，告知工程設計高頻的存于，原則的信息，能夠要求這些原則加以利用，且能結(jié)構(gòu)的獎勵制度，鼓勵設計師，它考慮到了這些原則。高頻工程的原則可能不是十分便利，有說服力的，或容易使用，但我懷疑相對較少的努力要避免使用不同的尺度上不同的控制面板布局為倆個相同的表盤和子系統(tǒng)或相鄰倆個類似的，甚至相同的子系統(tǒng)，或放于幾乎是無法避免的安全裝置中的關(guān)鍵領(lǐng)域。錯誤的設計，很多的例子（塞米納拉，岡薩1976（1980100系統(tǒng)中使用的約（1982，研究了過熱船只，且于海軍研究咨詢委員會的居所資助計劃的方案（1980。你也能夠談于車庫機械師。），其后果是由運營者承擔。災難缺乏良好的宣傳，工計不良，是由大家來判斷別人是自私。即使于設計知識貧困變得普遍，作為核控制室，奧拉斯證明新軍步槍拜斯維修問（1981們的成本相對較低的事業(yè)。獎勵工作的規(guī)范組織的領(lǐng)導人就于于誰決定以外的地方于這些設備的有效性能。上訴的權(quán)力的速度，機動性和輕松勝出之上考慮易維護和操作方便的選擇設計，仍有壹些內(nèi)部的顧問人員誰能夠提醒到這壹點。行政獎勵是選擇最新和最先進的設計，即使它們沒有經(jīng)過測試。幾年后，當系統(tǒng)交付及運營，行政機關(guān)已經(jīng)提出，如果他或她幾乎是于壹個軍事組織，它強制輪換的倆，三年，或者如果沒有，行政機關(guān)能夠歸咎于技術(shù)，使設計的承諾對目前復雜的。高風險，高科技系統(tǒng)已經(jīng)和事后的小地方的歷史，獎勵必須由目前的活動。無論是高層管理人員或不忽略高頻設計，其后果相當貧困的措施取決于對較大型系統(tǒng)，其中存于的組織。阿考慮對比的錯誤，避免航空運輸系統(tǒng)和錯誤誘導的海上運輸系統(tǒng)將首先說明如何管理的類別將難以忽視高頻，而那些于第二次會發(fā)現(xiàn)很容易，甚至有利可圖的航空運輸制度，績效管理制度的影響，通過獎勵的利潤情況和性能故障??即影響利潤和聲譽。故障接收媒體報道和徹底的調(diào)查和公開的利益不同的當事方和（管理機構(gòu)，聯(lián)邦航空管理局，壹個獨??的安全委員會，國家運輸安全委員會和飛行員工會），以及未能確定的原因有法律和保險的后果。該系統(tǒng)的用戶能夠退出，且使用其他系統(tǒng)（航空公司）或其他運輸方式于壹定程）是相對簡單的，可用，適合小規(guī)模的維修人員和小系統(tǒng)業(yè)者（倆個或三個船員，倆個或三個空中交通管制員，壹個小維修）。合理兼容獨??人士（制造商，航空公司，工會，管理機構(gòu)，以及空中交通控制系統(tǒng)）作為相互制衡的航空公司和利益，乘客和控制器（例如，減少擠塞節(jié)省燃料，時間空氣，降低互動的復雜性。（那么，軍等系統(tǒng)，他們?nèi)狈ψ钌厦娴暮Ｑ筮\輸系統(tǒng)是國際性的，但當事國利益相互矛盾，因此壹些規(guī)定是有效的。經(jīng)濟損失是很少注意吸收和傳遞到最終消費者，和人類的損失限于最初的人員和船員。環(huán)境是非常敵對，自然災害和相互作用船舶危險是間斷性的，比較難以預測，分布于長的時間跨度，限制了學習，經(jīng)驗和常規(guī)化，有效的保障。生產(chǎn)高，競爭壓力相對不受管制。事故原因的分析是困難和阻礙國家利益，弱弱的監(jiān)管機構(gòu)和工會，占沉沒的船只和船員，不可靠的，重建缺乏事故監(jiān)測數(shù)據(jù)。加強（集中系統(tǒng)的命令于壹個日益互動，于下面討論。該系統(tǒng)對比航空公司和海洋是佩羅闡述（1984。因此，該組織的性質(zhì)有壹個HFS影響高層管理人員的注意，以支付，這轉(zhuǎn)變的工程師分析，從設計到高層管理人員和服務的角度把這個問題：對于某些系統(tǒng)，良好的人力因素的設計是不很關(guān)聯(lián)的高層管理人員，但它肯定是飛行員和鍋爐操作員于軍事和航海。壹個隱含的觀點是，HFEs們的努力宣傳他們的積極支持。這種宣傳會，動員別人把管理人員的壓力于最前面。這將是很難做到的國防合同和海洋的設計，但它不會是不可能的。例如，根（1982（了更大的效益）的培訓走向橋的團隊，所設計的設備，正于反映了負責控制人員于團隊合作的潛力，而不是集中。或許，這將是不可能作出回避制度的結(jié)構(gòu)性變革，從而使海洋運輸壹明顯的錯誤，只是因為它可能無法使航空運輸系統(tǒng)的錯誤誘導系統(tǒng)。然而，更能夠做和海洋運輸，均是考慮到組織因素。（1）（2）自己設計的工程師誰寫的規(guī)格（或于某些個案設計和建造系統(tǒng)）的設計的重要性良好的高頻？組織理論家關(guān)注這個社會的組織結(jié)構(gòu)會回答：“當然。”他們不會，可是，所有的經(jīng)理均認為，這樣做是為了輸出居所資助計劃予以考慮，任何超過他們能夠命令努力工作，忠誠，或質(zhì)量。事實上，書面命令只造福，是提供法律支持紀律應該是方便，甚至是必要的。理論家會，而是強調(diào)不唐突的控制。例如，高層管理人員能夠控制的設計人員使用的處所，而不是試圖控制他們的行為直接（佩羅，1977）如下：確保HFEs于身體附近的設計師，使他們能夠建??互動和非正式的個人和團體的債券。HF訓，從而提高了HFE的地位。HFE撰寫和散發(fā)HFEs方案的貢獻。切不發(fā)送信號）。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