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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.
©The unconscious consumer ©Interplas ©Ana Pinedo et Valeria DiagoREFERENCES
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 21èmeCongrès 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