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HOF in Practice

How can I integrate HOF in my SMS?

The organisation shows that the use of a systematic Human and Organisational Factors (HOF) approach (with qualified HOF staff) in targeting risk is an integral part of the Safety Management System (SMS).

HOF 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.

When should integrating HOF take place?

Three stages 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 organisational 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…

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.


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.


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 organisational factors (e.g. management system, organisational structure, governance, resources). Individuals and organisational and technology issues can be seen to have contributed to the accident at the Fukushima Daiichi nuclear power

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 organisational 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 HOF?

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)