How do perturbation training contribute to safety? The unexpected and the unthought as means to design perturbations in safety training

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How do perturbation training contribute to safety? The

unexpected and the unthought as means to design

perturbations in safety training

Simon Flandin, Germain Poizat

To cite this version:

Simon Flandin, Germain Poizat. How do perturbation training contribute to safety? The unexpected and the unthought as means to design perturbations in safety training. EARLI SIG 14 Conference 2018, Sep 2018, Genève, Switzerland. pp.12 - 14. �hal-01877224�

EARLI SIG 14 18’ - University of Geneva – Geneva, September 12-14

How do perturbation training contribute to safety?

The unexpected and the unthought as means to

design perturbations in safety training

Simon Flandin & Germain Poizat

simon.flandin[at]unige.ch

📍

germain.poizat[at]unige.ch

CRAFT research team, University of Geneva

FACULTÉ DE PSYCHOLOGIE ET DES SCIENCES DE L’ÉDUCATION ÉQUIPE CRAFT, LABORATOIRE RIFT

An agenda of design-basededucational researchaddressing

contemporary issues (Poizat, Durand, & Theureau, 2016)

In practical contexts in which:

•

No stable and established knowledge curriculum is formalized and available yet,

such as in emerging or transforming activities (e.g., higher education)

•

Rapid knowledge improvements occur, including disruptive technological

development (e.g., declining craft trades)

•

Operators have to manage particularly complex, dynamic, evanescent,

multi-finalized situations (e.g., crisis situations)

•

Operators have to deal with contradictions in injunctions that can generate

dilemmas (e.g., in public systems of healthcare, execution of court decisions...)

•

Operators have to manage unexpected - or even unthinkable - situations, combined

with high stakes or even high risks (relating, for example, to health and safety of

Theoretical background/basis for a renewal of educational and

training practices (Flandin, Poizat, & Durand, 2018)

Addressing a paradoxal theoretical question: how to educate/train operators to novel

and umpredictable situations?

•

Implies to switch from a knowledge/curriculum-driven educational approach to a

dynamic/enactive systems approach (Maturana & Varela, 1991)

•

Developing the ability to make sense (/sensemaking) > knowledge

learning/improving

•

Developing dispositions to act (/feel/perceive/think/anticipate/watch/commit…)

that are complex, hard to identifiy and even more to modelize > stable and

segmented competencies

A researchproject in industrial safety

“Training programmes in the field of industrial safety no

longer seem to be yielding the expected results.”

Safety training methodsthat are not knowledge/curriculum-driven…

… mostly build on the conceptual field of resilience, defined by Hollnagel (2014)

as “the ability of the organization to adjust its functioning prior to (1), during

(2), and/or following (3) a shock or disturbance, so that this system can sustain

required operationsunder both expected and unexpected conditions”.

1. Training to ensure ordinary safety

2. Training to cope with deteriorating situations

3. Training to respond to crisis

Safety training methodsthat are not knowledge/curriculum-driven

1. Ensuring ordinary safety

- Collective mindfulness

Le

Coze,

Périnet,

&

Herchin,

2010

Perinet, Flandin, Bendris, Leprince, & Le Coze,

accepted ©picture1&2

Safety training methodsthat are not knowledge/curriculum-driven

2. Coping with deteriorating situations

- Emergency and abnormal situations

Malakis & Kontogiannis, 2008, 2012

- Uncertainty scenarios

Rankin et al., 2011 - ©picture1

Saurin et al., 2014 - ©picture2

- Escalating situations

Bergström, Dahlström, Dekker, & Petersen, 2011

- Compliance context training

Safety training methodsthat are not knowledge/curriculum-driven

3. Responding to crisis

- Operational resilience training

Bergström, Henriqson, & Dahlström, 2011

- Training for taking improvised roles

Lundberg & Rankin, 2013 - ©picture1

- Perturbation training / Team training

Gorman et al., 2010 - ©picture2

Perturbation for training purpose : definitions

“Perturbation is a meaningful phenomenon that can expand from a slight

discomfort to a disrupting

shock, and that is promising in terms of meta-stability, i.e the premise for major rebalancing and a future state of more

integrated individuation.”

“Perturbation is an extrinsic application of force that briefly disrupts a

dynamic process, forcing the reacquisition of a new stable trajectory, and

is typically used to probe the stability of that process”.

Poizat & Flandin, submitted – Enactive approach

for publication).

Perturbation for training purpose : design principles

Perturbations of the collective activity system can be created by (Gorman, 2018):

•

Interfering with team communication and forcing them to acquire new

communication routes to accomplish the task

•

Equipment malfunction that forces the team to perform the task in new ways

•

Suddenly changing task requirements by telling them to perform some ad hoc,

unexpected task

Perturbations of the individual activity can be created by (Poizat & Flandin,

submitted for publication):

•

Introducing "un-expected” disturbing events: rare but annoying problems (of

the realm of the possible but still unexpected)

•

Introducing “un-thought” disturbing events: "in-conceivable”, “beyond the

design basis” problems (that one would not have thought possible)

PROBABILITY OF OCCURRENCE

DANGER

Typical events

(the most plausible)

Critical events

(the most difficult to cope with)

An exploratory study in perturbation training in a gas plant

Training scenario

Crisis exercise: simulation of a “beyond

behind basis” accident involving the

(fictional) death of two on-call agents

Method

Data collection

Ergonomics methods of direct observations,

field notes, and retrospective interviews

Data analysis

The enactive framework of the course of

action (Theureau, 2005)

Head of Safety Station Director Crisis Advisor Observator Trainer

Watch Officer in training

Human Factors Advisor

Watch Officer in training

The watch officer

gets aware of a

breakdown

️

The watch officer

hears an explosion

and so call the

firemen

While he’s being

warning him, he

suddenly realizes

that the 2 on-call

agents may be

injured or dead

☠

_👷

☠

Analysis of the main perturbating episodes

He activates the

emergency safety

procedure 🔔

The 2 on-call agents

go in the

breakdown area

️

He tries four times

to call the on-call

agents

… but they never

answer even

though it is strictly

mandatory

The watch officer

gets bewildered as

the scenario goes

impossible for him

️

️

After 10 minutes of

bewilderment, the

watch officer

deviates from the

procedure as he

realizes that it has

become

insufficient to

overcome the

problem

He finds

unexpected new

resources looking at

the dynamic

planning and calls

another agent on

the station

He calls the on-call

agents and ask for a

« lift of doubt »

The simulation

ends up with

conventional

procedures, almost

not involving the

watch officer

1

2

3

Analysis of the main perturbating episode: summary

The perturbation led successively the watch officer:

1. to an initial state of bewilderment and collapse of sensemaking as the situation got

unexpected (he knows that (i) people can die; (ii) explosions can injure; knowledge is

available but he can’t make sense)

2. to accept his state of uncertainty and to look for new resources and ways to achieve

his objective, even though it involved moving away from the procedure;

3. to make several wrong hypotheses before finally understanding what happened.

Possible training outcomes in the domain of the unexpected

(initially not-anticipable for the agent)

- Prefiguration of a plausible case (eg, an explosion), which does not mitigate the

surprise of the agent in a real accident, but is likely to reduce the time of confusion (or

even stupefaction) that is characteristic of accidental situations.

- Benefit of a set of experiences of perception and meaning (emergence of emotions,

clues, marks) related to this case, which one can think that they will increase the

reactivity of the agent in a real accident.

- Prefiguring a sustainable solution or configuration that is more likely to be

reconfigured in a similar way in a real accident situation.

Possible training outcomes in the domain of the unthought

(initially held for impossible by the agent)

- Expansion of the understanding, i.e. the capacity to make sense

(i) on critical events (what may happen, eg, the death of a colleague) and

(ii) in critical events (what can be done, eg, deviate from the procedure and improvise)

- Development of a sensitivity to a need for improvisation, and to a "possibility of the

impossible”, following the abduction: “if the death of a colleague is not impossible, then

other events supposedly impossible are not.”

- Identification or creation of marks, resources, “buoys” to be hung up in case of

emergency and uncertainty (e.g., dynamic planning of operations).

Comments

•

A need for a "dosage" in the design, in order to cause sufficiently high

disturbances to disrupt activity significantly, but in a sufficiently

controlled manner to guard against adverse effects.

•

A need to train trainers to design and use such perturbation

methods.

•

The challenge of “perturbation acceptability” for all stakeholders in

training implementation: decision makers, trainers and trainees can

each be reluctant (Schot et al., submitted for publication).

•

Perturbations as “desirable difficulties” in training (Bjork, 1994) needs

a switch from a culture of performance and safety to a culture of

doubt and vulnerability.

REFERENCES

Bergström, J., Dahlström, N., Dekker, S., & Petersen, K. (2011). Training organizational resilience in escalating situations. In E. Hollnagel, J. Pariès, D. Woods, & J. Reathall. (Eds.) Resilience engineering in practice: A guidebook (pp. 45-56). Ashgate Publishing, Ltd.

Bergström, J., Henriqson, E., & Dahlström, N. (2011). From crew resource management to operational resilience. In Proceedings

of the 4th Resilience Engineering Symposium, 8-10 June 2011, Sophia Antipolis, France.

Bjork, R. A. (2013). Desirable difficulties perspective on learning. Encyclopedia of the mind, 4, 134-146.

Flandin, S., Poizat, G. & Durand, M. (2018). Improving resilience in high-risk organizations. Principles for the design of innovative training situations. Development and Learning in Organizations:an International Journal, 32(2), 9-12.

Foundation for an Industrial Safety Culture (2015). Skills and competencies for industrial safety. Strategic Analysis. Toulouse: FONCSI.

Gorman, J. C., Cooke, N. J., & Amazeen, P. G. (2010). Training adaptive teams. Human Factors, 52(2), 295-307.

Grøtan, T. O., Wærø, I., van der Vorm J.K.J., van der Beek F.A., & Zuiderwijk D.C. (2017). Using gaming and resilience engineering principles to energize a situated resilience training of front-end operators and managers. In L. Walls, M. Revie & T. Bedford (Eds.). Risk, Reliability and Safety: Innovating Theory and Practice (pp. 2246-2253). London:Taylor & Francis Group.

Hollnagel, E. (2014). Safety - I and safety – II: The past and futureof safety management. Ashgate Publishing, Ltd.

Le Coze, J. C., Perinet, R., & Herchin, N. (2010). Opérationnalisation de la résilience par l'intermédiaire de la vigilance collective, son appropriation au sein d'une approche interdisciplinaire en sécurité industrielle. Actes du Congrès de la Société d'Ergonomie

REFERENCES

Lundberg, J., & Rankin, A. (2014). Resilience and vulnerability of small flexible crisis response teams: implications for training and preparation. Cognition, technology & work, 16(2), 143-155.

Malakis, S., & Kontogiannis, T. (2008). Cognitive strategies in emergency and abnormal situations training: implications for resilience in air traffic control. In Proceedings of the 3rd Resilience Engineering Symposium, October 28-30, 2008, Juan-les-pins, France.

Malakis, S., & Kontogiannis, T. (2012). Refresher Training for Air Traffic Controllers: Is It Adequate to Meet the Challenges of Emergencies and Abnormal Situations?. The International Journal of Aviation Psychology, 22(1), 59-77.

Maturana, H. R., & Varela, F. J. (1991). Autopoiesis and cognition: The realization of the living (Vol. 42). Springer Science & Business Media.

Perinet, R., Flandin, S., Bendris, M., Leprince, P., & Le Coze, J.-C. (accepted). La démarche Vigilance Collective : prendre du recul sur la gestion des imprévus et la complexité du quotidien. Communication soumise au 21ème_{Congrès Lambda Mu de}

l’Institut de Maitrise Des Risques, Rouen, 16-18 octobre.

Poizat, G., Durand, M., & Theureau, J. (2016). The challenges of activity analysis for training objectives. Le travail humain,

79(3), 233-258.

Poizat, G., & Flandin, S. From sensemaking to activity that is meaningful for the actor: going beyond Weick’s theory with the course-of-action research program. Submitted for publication.

Rankin, A., Field, J., Wong, W., Eriksson, H., Rooney, C., & Lundberg, J. (2011). Scenario design for training systems in crisis management: Training resilience capabilities. In Proceedings of the 4th Resilience Engineering Symposium, June 8-11 2011, Sophia Antipolis, France.

REFERENCES

Saurin, T. A., Wachs, P., Righi, A. W., & Henriqson, E. (2014). The design of scenario-based training from the resilience engineering perspective: A study with grid electricians. Accident Analysis & Prevention, 68, 30-41.

Schot, S., Flandin, S., Goudeaux, A., Seferdjeli, L., & Poizat, G. Formation basée sur la perturbation : preuve de

concept par la conception d’un environnement numérique de formation en radiologie médicale.

[Perturbation-based training: proof of concept through the design of a digital training environment for medical radiology].

Submitted for publication.

Theureau J. (2003). Chapter 4 : Course-of-Action Analysis and Course-of-Action Centered Design. In: E. Hollnagel (Ed.),

EARLI SIG 14 18’ - University of Geneva – Geneva, September 12-14

How do perturbation training contribute to safety?

The unexpected and the unthought as means to

design perturbations in safety training

Simon Flandin & Germain Poizat

simon.flandin[at]unige.ch

📍

germain.poizat[at]unige.ch

CRAFT research team, University of Geneva

FACULTÉ DE PSYCHOLOGIE ET DES SCIENCES DE L’ÉDUCATION ÉQUIPE CRAFT, LABORATOIRE RIFT