（建筑工程管理）人因工程學(xué)

建筑工程管理人因工程學(xué)人因工程學(xué)的組織結(jié)構(gòu)作者：查爾斯佩羅人因工程學(xué)關(guān)心的是設(shè)備設(shè)計(jì)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(xué)給設(shè)計(jì)工程師建議，可是其組織內(nèi)容又會(huì)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(duì)和工業(yè)的高層人事管理不同于好的人因設(shè)計(jì)，展示了社會(huì)機(jī)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(cuò)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(rèn)知地圖和心智模式的設(shè)備和系統(tǒng)設(shè)計(jì)，以及技術(shù)社會(huì)的結(jié)構(gòu)模式。介紹15的軍隊(duì)武器不能瞄準(zhǔn)甚至有時(shí)不能開火，如此昂貴的精密的軍用飛機(jī)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(gè)科技奇跡即能解決人和機(jī)器問題的壹個(gè)防沖突雷達(dá)設(shè)置。這篇文章講述了壹個(gè)尚未探索的方面—人和機(jī)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(shè)備的設(shè)計(jì)，以及如何運(yùn)用新的設(shè)備反應(yīng)其組織結(jié)構(gòu)。設(shè)備設(shè)計(jì)者有責(zé)任采取運(yùn)營者和維修人員的特點(diǎn)來考慮他們的設(shè)計(jì)，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(dāng)下的數(shù)字叫人類工程學(xué)。HFEsHFEs對(duì)社會(huì)和組織環(huán)境中的作用。鑒于很多恐怖的事情比如設(shè)備的設(shè)計(jì)不良難以適應(yīng)人類的能力，我確保第壹個(gè)任務(wù)是參加操作員的生理和心理的特點(diǎn)，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(shè)計(jì)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(fēng)暴工作于從軍事和工業(yè)設(shè)備，電子產(chǎn)品更高的性能水平海，霧方向機(jī)場）或者接近人口密度，瞬時(shí)通訊于很遠(yuǎn)的距更高的系統(tǒng)性能已經(jīng)達(dá)到了三種方式改變運(yùn)營者的作用：要求更高的技能和服務(wù)（高壓，高負(fù)荷工作，更復(fù)雜的任務(wù)，需要高認(rèn)知特點(diǎn)的商船甲板人員，宇航員的作用，飛行員和航空運(yùn)輸于他們參觀的職責(zé)，核，化學(xué)工廠運(yùn)營者于緊急情況下的關(guān)鍵階段，以及像戰(zhàn)斗機(jī)飛行員和坦克指揮官壹般。被動(dòng)監(jiān)測于長的特點(diǎn)，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(xué)工廠運(yùn)營者，如區(qū)分了靜態(tài)的陰極射線管敵方潛艇的軌道，機(jī)載監(jiān)視系統(tǒng)。所有這些系統(tǒng)均具有于運(yùn)營商的角色，自動(dòng)化裝置的例子，第三改變完全繞過運(yùn)營商。這些變化的系統(tǒng)中，導(dǎo)致于運(yùn)營商及其設(shè)備之間的界面設(shè)計(jì)問題，于維修間的人監(jiān)測模式鼓勵(lì)非技術(shù)化，單調(diào)和低系統(tǒng)的理解，導(dǎo)致精神低落，產(chǎn)量低，缺乏技能和應(yīng)付意外緊急情況或甚至變化的系統(tǒng)狀態(tài)。運(yùn)營者進(jìn)行設(shè)計(jì)，通過自動(dòng)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(yù)能力。于緊急情況下干預(yù)或當(dāng)不正常的條件下，設(shè)備復(fù)雜的事實(shí)。它的維修保養(yǎng)往往成小包裝，無法使空間展開。這種先進(jìn)的系統(tǒng)的高費(fèi)用的建設(shè)和營運(yùn)可減少訓(xùn)練時(shí)間，增加了失敗的代價(jià)。有時(shí)是很難讓操作員使用新設(shè)備去提高系統(tǒng)性能，因?yàn)樗麄儾恍湃嗡鼈儯l(fā)現(xiàn)它們也難以操作，或者覺得他們使之更難以達(dá)到的性能指標(biāo)。海軍飛行員有抬頭顯于他們的擋風(fēng)玻璃上，有明確的塑料預(yù)測他們認(rèn)為實(shí)際的甲板上，從而于飛機(jī)配置該計(jì)算機(jī)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(dān)心這會(huì)導(dǎo)致它的場合發(fā)生故障時(shí)所需要的技能衰退，且認(rèn)為他們的經(jīng)驗(yàn)（1980船用甲板人員忽視出于同樣的原因復(fù)雜的防撞設(shè)備，仍因?yàn)樗鼘?shí)際上增加了工作量和分散他們的溝通及1981產(chǎn)目標(biāo)（佩偌,1984。因此，系統(tǒng)設(shè)計(jì)了關(guān)聯(lián)的決定和對(duì)運(yùn)營者的過分要求，單HFE的任務(wù)是提供意見，以設(shè)計(jì)工程師如何設(shè)計(jì)的設(shè)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(jī)均應(yīng)該右轉(zhuǎn)，插座應(yīng)設(shè)計(jì)所以，錯(cuò)誤的插頭（2際設(shè)計(jì)和提出改革建議;（3）或可能實(shí)際上和工程師，設(shè)計(jì)演變。的角度見，限制條件，這是孤??HFE），設(shè)計(jì)工程師關(guān)切體位限制（范圍，強(qiáng)度，視覺和運(yùn)動(dòng)靈敏度，響應(yīng)時(shí)間，認(rèn)知能力和記憶體限制，以及工作負(fù)載的能力。雖然設(shè)計(jì)者往往不了解這些限制運(yùn)營和設(shè)營者的職能。此外，它是明顯的，許多文獻(xiàn)和實(shí)地觀察，HFEs面的認(rèn)識(shí)，于他們的組織以及運(yùn)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(shè)備，但如何將這些全部是該組織所影響的社會(huì)結(jié)構(gòu)和影111社會(huì)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(shè)計(jì)最終，于設(shè)計(jì)上忽視居所資助計(jì)劃于工程中可能于于他們消費(fèi)這些設(shè)計(jì)中，無論是誰，有設(shè)計(jì)了他們的房子或出示指定誰為供應(yīng)商。壹個(gè)組織的分析師將放于解釋沒有什么價(jià)值，設(shè)計(jì)工程師忽略或忽視他們的居所資助計(jì)劃，因?yàn)樗麄儾恢赖?，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?yàn)橐夹┪墨I(xiàn)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(shè)計(jì)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(jiǎng)勵(lì)制度，鼓勵(lì)設(shè)計(jì)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(duì)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(gè)相同的表盤和子系統(tǒng)或相鄰倆個(gè)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(cuò)誤的設(shè)計(jì)，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(huì)的居所資助計(jì)劃的方案（1980。你也能夠談?dòng)谲噹鞕C(jī)械師。），其后果是由運(yùn)營者承擔(dān)。災(zāi)難缺乏良好的宣傳，工計(jì)不良，是由大家來判斷別人是自私。即使于設(shè)計(jì)知識(shí)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(duì)較低的事業(yè)。獎(jiǎng)勵(lì)工作的規(guī)范組織的領(lǐng)導(dǎo)人就于于誰決定以外的地方于這些設(shè)備的有效性能。上訴的權(quán)力的速度，機(jī)動(dòng)性和輕松勝出之上考慮易維護(hù)和操作方便的選擇設(shè)計(jì)，仍有壹些內(nèi)部的顧問人員誰能夠提醒到這壹點(diǎn)。行政獎(jiǎng)勵(lì)是選擇最新和最先進(jìn)的設(shè)計(jì)，即使它們沒有經(jīng)過測試。幾年后，當(dāng)系統(tǒng)交付及運(yùn)營，行政機(jī)關(guān)已經(jīng)提出，如果他或她幾乎是于壹個(gè)軍事組織，它強(qiáng)制輪換的倆，三年，或者如果沒有，行政機(jī)關(guān)能夠歸咎于技術(shù)，使設(shè)計(jì)的承諾對(duì)目前復(fù)雜的。高風(fēng)險(xiǎn)，高科技系統(tǒng)已經(jīng)和事后的小地方的歷史，獎(jiǎng)勵(lì)必須由目前的活動(dòng)。無論是高層管理人員或不忽略高頻設(shè)計(jì)，其后果相當(dāng)貧困的措施取決于對(duì)較大型系統(tǒng)，其中存于的組織。阿考慮對(duì)比的錯(cuò)誤，避免航空運(yùn)輸系統(tǒng)和錯(cuò)誤誘導(dǎo)的海上運(yùn)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(huì)發(fā)現(xiàn)很容易，甚至有利可圖的航空運(yùn)輸制度，績效管理制度的影響，通過獎(jiǎng)勵(lì)的利潤情況和性能故障??即影響利潤和聲譽(yù)。故障接收媒體報(bào)道和徹底的調(diào)查和公開的利益不同的當(dāng)事方和（管理機(jī)構(gòu)，聯(lián)邦航空管理局，壹個(gè)獨(dú)??的安全委員會(huì)，國家運(yùn)輸安全委員會(huì)和飛行員工會(huì)），以及未能確定的原因有法律和保險(xiǎn)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(yùn)輸方式于壹定程）是相對(duì)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(gè)或三個(gè)船員，倆個(gè)或三個(gè)空中交通管制員，壹個(gè)小維修）。合理兼容獨(dú)??人士（制造商，航空公司，工會(huì)，管理機(jī)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(shí)間空氣，降低互動(dòng)的復(fù)雜性。（那么，軍等系統(tǒng)，他們?nèi)狈ψ钌厦娴暮Ｑ筮\(yùn)輸系統(tǒng)是國際性的，但當(dāng)事國利益相互矛盾，因此壹些規(guī)定是有效的。經(jīng)濟(jì)損失是很少注意吸收和傳遞到最終消費(fèi)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(duì)，自然災(zāi)害和相互作用船舶危險(xiǎn)是間斷性的，比較難以預(yù)測，分布于長的時(shí)間跨度，限制了學(xué)習(xí)，經(jīng)驗(yàn)和常規(guī)化，有效的保障。生產(chǎn)高，競爭壓力相對(duì)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(jī)構(gòu)和工會(huì)，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(qiáng)（集中系統(tǒng)的命令于壹個(gè)日益互動(dòng)，于下面討論。該系統(tǒng)對(duì)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(gè)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(shè)計(jì)到高層管理人員和服務(wù)的角度把這個(gè)問題：對(duì)于某些系統(tǒng)，良好的人力因素的設(shè)計(jì)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(gè)隱含的觀點(diǎn)是，HFEs們的努力宣傳他們的積極支持。這種宣傳會(huì)，動(dòng)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(shè)計(jì)，但它不會(huì)是不可能的。例如，根（1982（了更大的效益）的培訓(xùn)走向橋的團(tuán)隊(duì)，所設(shè)計(jì)的設(shè)備，正于反映了負(fù)責(zé)控制人員于團(tuán)隊(duì)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(yùn)輸壹明顯的錯(cuò)誤，只是因?yàn)樗赡軣o法使航空運(yùn)輸系統(tǒng)的錯(cuò)誤誘導(dǎo)系統(tǒng)。然而，更能夠做和海洋運(yùn)輸，均是考慮到組織因素。（1）（2）自己設(shè)計(jì)的工程師誰寫的規(guī)格（或于某些個(gè)案設(shè)計(jì)和建造系統(tǒng)）的設(shè)計(jì)的重要性良好的高頻？組織理論家關(guān)注這個(gè)社會(huì)的組織結(jié)構(gòu)會(huì)回答：“當(dāng)然?！彼麄儾粫?huì)，可是，所有的經(jīng)理均認(rèn)為，這樣做是為了輸出居所資助計(jì)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(shí)上，書面命令只造福，是提供法律支持紀(jì)律應(yīng)該是方便，甚至是必要的。理論家會(huì)，而是強(qiáng)調(diào)不唐突的控制。例如，高層管理人員能夠控制的設(shè)計(jì)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(shè)計(jì)師，使他們能夠建??互動(dòng)和非正式的個(gè)人和團(tuán)體的債券。HF訓(xùn)，從而提高了HFE的地位。HFE撰寫和散發(fā)HFEs方案的貢獻(xiàn)。切不發(fā)送信號(hào)）。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