European Railway Agency - ERA

Making the railway system work better for society.

Human and Organisational Factors (HOF)

To comply with current legislation the organisation must demonstrate a systematic approach to integrating and managing Human and Organisational Factors (HOF) within the Safety Management System (SMS). HOF is a multidisciplinary field focusing on how to increase safety, enhance performance as well as increase user satisfaction.

According to the International Ergonomics Association, “ergonomics (or human factors) is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and other methods to design in order to optimize human well-being and overall system performance”.

HOF integrates knowledge in social sciences such as Management Science, Psychology, Sociology, Design Science, Political Science, to enlarge the scope of study and investigation while considering organisational, institutional, cultural or political contributors to safety. The term ‘organisational’ has been introduced to highlight the organisational level of analysis and not only the individual level although obviously organisations are composed of individuals.

Besides supporting the integration of safety at the design stage, the HOF approach provides concepts and methods to identify the gaps between the task (work as prescribed or expected), and the activity (work as actually performed or experienced and reported by workers). These gaps, whether concerning the task or/and the activity are problematic as they are a source of residual risk and need to be taken into account.

This allows a better managing of workplace reality in complex organisations such as railway socio-technical systems, which is critical to lead to safety improvements.

In practice, what is meant by HOF? What is an example of these “interactions”?

HOF refers to the interactions among system components and humans, considering their behaviors, at all levels such as individual, situational, group, organisational or cultural.

Examples of interactions, observable at several levels, can be found in: job design, workload, fatigue, procedures, competence management, working conditions, organisational and technological change, staffing, reporting culture, systemic investigations and audits, or the safety culture of the organisation.

The notion of interaction is not easy to grasp. For example, we can consider that an error can be caused by workload. Although this is “HOF reasoning”, it can be expanded as a function of the situation. Other factors could have played a (positive or negative) role. An error like missing information in a critical communication can be the result of the combination of factors like job design, rigid staffing, unlearned situation, lack of risk analysis or unmonitored workload. Because of these “uncontrolled” interactions, people in the field often adapt the procedures to the available resources and circumstances.

If these risky behaviours or “errors” are not investigated from a system point of view (and their root causes eliminated), they will be repeated, even generating a new informal but tolerated task, with more serious consequences.

Furthermore, threatening to punish or punishing people in these cases will be perceived not only as unfair, but also will produce a limited effect and for a short period of time. As an alternative, maybe you will propose more training for those operators? Ok, but with a high risk for an accentuation of the difference between what is expected in theory and what is really possible in practice in the field...

It is then important to remember that these interactions stimulate people to behave in this adaptive way. HOF are not only considering people but also the context and the real work situations.

SMS needs the people actually using it to be implicated, why?

People in the field know better than others those interactions which impair their own behaviours and therefore safety. This is why people who “operate” the SMS on a regular basis have to be implicated in changes as soon as possible and questioned regularly about variability and risks in situations.

For example, there is variability in behaviours, in rules conditions, in working conditions, in the resources available. In our railway systems, there are still a lot of residual risks under control most of the time, but not always: risks in competing priorities, in levels of complexity left in situations, in technologies not always based on users, etc.

Performance and specifically safety performance needs to identify, maintain and reinforce any positive variability, and even residual risk managed with success. It needs to identify what can be learned from any unacceptable variability or risk. It also needs to consider corrections or adaptations - if not, continual improvement will not be possible.

Nothing in our real world is and will stay optimal by its self: our SMS need to be put into practice, brought alive every day and continuously improved. HOF concepts and methods are helpful here.

In practice, HOF is also a mind-set, but what is this?

Finally, HOF is also a specific mind-set, a set of values. This is made of mutual trust, respecting the end-user as a client and making efforts to understand its real working conditions; it is a mind-set based on a multi causality and systemic reasoning, enhancing continual improvement and positive safety behaviours.

In what other domains than railways are HOF relevant?

Railways are not the only high-risk domain where HOF are important. Other domains such as nuclear, aviation, healthcare, oil and gas – any high-risk domain where sociotechnical systems function – integration of HOF is essential.


“Unsafe medication practices and medication errors are a leading cause of avoidable harm in health care systems across the world. Globally, the cost associated with medication errors has been estimated at US$ 42 billion annually, not counting lost wages, productivity, or health care costs. This amounts to almost 1% of global expenditure on health. Medication errors occur when weak medication systems and/or human factors such as fatigue of personnel, poor working conditions, workflow interruptions or staff shortages affect prescribing, transcribing, dispensing, administration and monitoring practices, which can then result in severe harm, disability and even death.”

WHO report on patient safety March 2018


“During the second half of the 20th century the technical environment changed and the focus of attention shifted from technological problems to human factors problems and finally to problems with organisations and safety culture.”
Eurocontrol From Safety-I to Safety-II: A White Paper


“The systemic approach to safety addresses the whole system by considering the dynamic interactions within and among all relevant factors of the system —individual factors (e.g. knowledge, thoughts, decisions, actions), technical factors (e.g. technology, tools, equipment), and organizational factors (e.g. management system, organizational structure, governance, resources).

Individuals and organizational and technology issues can be seen to have contributed to the accident at the Fukushima Daiichi nuclear power

IAEA Report on Human and Organizational Factors in Nuclear Safety in the Light of the Accident at the Fukushima Daiichi Nuclear Power Plant. May 2013.

Oil and gas

In the oil and gas industry Human Factors is an essential component in the effort to operate in a safe and efficient manner. Areas where Human Factors has a key role include:

  • Design of tools, equipment and user interfaces in a way that augments the user’s work performance
  • Human and organizational factors in risk assessments and emergency preparedness planning
  • Human behaviour and cognition in accident causation
  • Efficient decision making and teamwork in stressful or critical situations
  • Safety culture and safety behaviour improvement programmes
  • Organisational reliability

Human Factors aims to achieve outstanding performance by proactively identifying risks and improvement opportunities, promoting Safety Leadership and designing improvement strategies, applying best practice tools, and supporting implementation to business and operational functions.

I am not a psychologist, how can I understand Human and Organisational Factors?

It is true that psychologists work in the field of human and organisational factors, performing research and using what they know about human behavior, perception, attention, well-being and motivation etc. to improve the work environment and working conditions but other domains are involved as well such as ergonomics, systems engineers…

As somebody working in the railways your contribution is important as well in integrating HOF in safe performance. In fact, to understand how HOFs are working, you can just ask yourself only one question: What can happen if HOF are not taking into account? (Reasoning by absurdity): when someone needs to exert a large proportion of their strength to complete a task but he is more likely to be exhausted. When there is an atmosphere of lack of motivation and job satisfaction. When the tasks are not well understood in detail etc.…

Through these questions and others, you can easily understand the importance of HOF even if you are not an expert, proceeding conversely can show how much it costs if you don’t take them into account and especially the gravity of the resulting accidents (Boeing 737max as example)

Why are Human and Organisational factors so important for safety?

Railway safety has improved (as in other high risk industries). At first the focus was on technical reliability. Secondly there was a formalisation of processes (SMS). Big improvements in safety performance have been made but improvements are levelling off and a plateau effect is being seen. Now it has become of prime importance to integrate human and organisational factors in order to continue to improve safety performance.

Human and Organisational factors

Aren’t humans the source of most errors which lead to accidents?

All errors are made by people, of course! However, all the processes of an SMS and all the units involved in its application (from design to continual improvement) vary naturally and carry residual risks. Sometimes this variability and these residual risks are considered as errors afterwards, because there were consequences. Moreover, since the consequences of field actions are more quickly visible or close to the bad result, we often overestimate the "weight" of field errors (i.e. the variability in behaviour and/or the residual risks people had to manage during the evolving of the situation).

Note that all the components of the socio-technical system have advantages, specific strengths as well as limits of use or weaknesses: but they are not always taken into account at the right time (cf. design, purchase, selection, risk analysis, training, planning, monitoring, recycling, maintenance,...). Remember: in a HOF-oriented analysis, the focus is on all sources of variability and all problematic residual risks left in the system. By doing so, any “error” becomes a potential opportunity for progress for the entire SMS!

Who is involved in integrating HOF? Who will benefit from integrating HOF?

You, as a human being are concerned by human and organisational factors. What makes you react with anxiety to a situation that two days ago should have made you feel more comfortable? Is the context different? Are you more stressed or tired? Why did you argue with your best friend on that subject that does not really matter whereas you never did before? The situation is always a new one even if the event is similar because so many details are different.

For a company, each staff member should be involved in integrating HOF, even though the impulse has to come from the top management that has to lead by example. For example, inside the company safety advisors, managers, supervisors, trainers and front-line workers should be involved. The company has also to identify all the safety related tasks that should be more focused and raise awareness of the people performing this task. HOF integration should also cover all contracted activities : contractors, designers and suppliers. The aim is to adapt the work situation to the worker to enable him to feel as comfortable as possible to perform his task. In order to assist people in carrying out their task, an organisation needs to understand how humans, (with their capabilities and limitations) use specifications to solve problems and take this knowledge into account when designing their work environment. The same goes for rules and regulations: as long as the workers implementing them are not considered when designing working procedures, they will be forced to break rules in order to get work done whenever contradictions or conflicts occur.

Everyone will benefit from HOF integration: workers who will have less accidents, the company which will increase its performance and improve its image and the society which will feel more confiden in railways.

When should integrating HOF take place?

Three times are considered:

  1. before (corresponding activity: design);
  2. during (corresponding activities: day-to-day, operations, maintenance …);
  3. after (corresponding activities: post-event, feedback or crisis management)

The first period, design, concerns this important step in the life of any solution when new systems or new organizational structures are envisioned.

Numerous methodological possibilities are proposed, from ‘user-centered design’ in ergonomics to ‘change management’ in sociology, for example. “Checklist” and “SMS review” (safety management system) are also approaches that are met and deployed in progress modifications, in which HOF should be kept in mind during the design phase.

The second period, day-to-day, corresponds to the operation of the activities such as train driving, dispatching or even maintenance in the framework or risk assessment.

Finally, the third period, post-event, is focalized on anomalies, incidents or accidents. It is the investigation phase when the aim is to find the causes.

For each of these periods, HOF approaches are available, from “causal trees” to “in-depth and systemic investigation,” or methods to analyses daily work situations: “safety visits” through “workplace analysis.”

Why now? 

Not only because of the application of the regulation 2018.762! A lot of enterprise and organisation have health and safety policies and practices. A lot of them already apply an ISO or CENELEC approach for their risks management. A lot of them, specifically because of the accident history in railways, are focused on the ergonomics for train drivers, for signalers, for heavy tasks on tracks, or mortal hazards like electricity or train vehicles, etc.

During the relevant certifications, we will insist on the identification and realignment of all those management activities in which HOFs are already taken into account. This realignment makes it possible to identify how to further improve HOF integration into the SMS.

Two important and well known perspectives are complementary here: having the good level of reactivity after an event in order to reduce the probability of its repetition, and, being proactive in design and risk analysis in order to anticipate the right actions to produce and reduce the risks at an acceptable level. This logic also applies to HOF: at an individual level, humans need feedback after an event and even need guidance to avoid it, and it is the same at the organisational level!

So, there is no best moment to start integrate HOF in your SMS: probably you already have a lot of these puzzle pieces…

How can I integrate HOF in my SMS

The organisation shows that the use of a systematic human and organisational factors approach (with qualified HOF staff) in targeting risk is an integral part of the SMS. Human and organisational factors involves taking a systemic perspective where the interactions between human, technological and organisational factors are considered through a lifecycle approach (including subcontractors) :

  • Management commitment to human and organisational factors is demonstrated in policies and objectives and in management and leadership behaviours. Training and procedure development is based on the task to be performed within its natural setting, which will help optimise both risk control and performance (e.g. task analysis, usability analysis, simulation, human HAZOP, bow-tie).
  • Setting goals, expectations and accountabilities in relation to safety behaviours at all levels of the organisation and to ensure timely feedback and communication.
  • Business objectives, management, operations, human performance, task and workplace design are considered. The analysis should identify all human and organisational factors and the performance influencing factors that will impact railway safety and the safety management activities needed to control risks. This includes using the present users’ experience in producing design requirements, analysing tasks to identify cognitive and physiological challenges, reducing the potential for erroneous performance through design by applying human factors guidelines such as different ISO or UIC standards, making workload and fatigue management analysis to ensure the personnel is capable of task performance, making risk analyses to identify potential problems and identifying compensatory actions for these. The procedure for communicating the outcomes of risk assessments.
  • Safety management activities related to support functions and systems, task design, staffing levels, training, design and use of equipment, procedures and communication protocols, should be identified.
  • Changes to roles, responsibilities, tools and equipment, work environments, processes and procedures are supported by an analysis of human and organisational factors matters to identify possible safety risks related to the change. Methods used could be, for example, task analysis, usability analysis, simulation, risk assessment, HAZOP and safety survey..
  • Identifying the safety critical work tasks and processes, and methods from the human and organisational factors domain are used for analyzing safety critical work tasks, e g task analysis, HTA, (hierarchical task analysis), TTA, (tabular task analysis). Professional human and organisational factors expertise should be used to select and apply appropriate methods.
  • Operational planning in connection with for example work schedules, fatigue management, stress, work environment (physical and psychosocial), workplaces and work processes etc.
  • Adequate resources in relation to the asset ensuring that human and organisational factors are considered and appropriately addressed.
  • The monitoring and investigations take a systemic perspective, that is, not just to look at the human, technological and organisational factors in their own right but also to emphasise the interactions between the factors.

What types of legal obligations relate to HOF in Railways?

The main legislation is composed of : -two directives that are to be transposed in your national legislation refer to the obligation to take HOF into account : Directive 89/391 on the introduction of measures to encourage improvements in the safety and health of workers at work and Directive 2016/798 on railway safety that imposes to railway undertakings and infrastructure managers to integrate human and organisational factors in their safety management system.

regulation 2018/762 establishing common safety methods on safety management system requirements that has reinforced this latter obligation by imposing to include HOF in risk assessment and mandating the demonstration from the organisation to have a systematic approach to integrating HOF within their SMS. This approach shall :

  1. (a) include the development of a strategy and the use of expertise and recognised methods from the field of human and organisational factors;
  2. (b) address risks associated with the design and use of equipment, tasks, working conditions and organisational arrangements, taking into account human capabilities as well as limitations, and the influences on human performance.

HOF in Railways