Sustainable Issues:

Mental Model & Systems Thinking,

and Human Factors

Adapted from Prof Lim Mong King (2016)

Updated by Dr Lum Kit Meng (2018)

Engineering Practice - Systems Thinking

1
Sustainability is defined as the ability to
maintain at a certain rate or level of
consumption/usage to avoid the depletion of
natural resources in order to maintain an
ecological balance.
• Sustainability encompasses both the economic,
environment, and the social elements

https://www.youtube.com/watch?v=_5r4loXPyx8

2
 causes  problems  symptoms
Higher Order Thinking Required to solve it … Mental Model
3
 Solving Sustainability Issues:
Higher Order Thinking Required
Albert Einstein:
We cannot expect to be able to resolve any complex
problem from within the same manner of thinking that
created it in the first place. Problems are best solved not on
the level where they appear to
Marcus Aurelius: occur but from a higher viewpoint.

Everything we hear is an opinion, not a fact. Everything

we see is a perspective, not the truth.
Mark Twain:
What gets us into trouble is not what we don’t know.
It’s what we know for sure that just ain’t so.”
4
 It’s All About Mental Model

Watch your mindset, it becomes your thoughts.

Watch your thoughts, they become your words.

Watch your words, they become your actions.

Watch your actions, they become your habits.

Watch your habits, they become your character.

Watch your character, it becomes your destiny.

Frank Outlaw

5
 Rethinking Thinking Using the Ladder of Inference
- Mental Model

By using the Ladder of Inference, we

https://www.youtu
be.com/watch?v=R
wiELtWVyVc
can learn to get back to the facts and
use our beliefs and experiences to
positively effect outcomes, rather
than allowing them to narrow our
field of judgment.
6
Using the reflexive loop, one can ask:
• Why have I chosen this course of action?
• Are there other actions I should have considered?
• What belief lead to that action? Was it well-founded?
• Why did I draw that conclusion? Is the conclusion sound?
• What am I assuming, and why? Are my assumptions valid?
• What data have I chosen to use and why? Have I selected data
rigorously?
• What are the real facts that I should be using? Are there other
facts I should consider?

With a new sense of reasoning and perhaps a wider field

of data and more considered assumptions, one can go
forward step-by-step up the rungs of the ladder again.
7
 Mental Models - How They Work

A mental model is an explanation of the thinking process about how

something works in the real world. Mental models can help shape
behavior and set an approach to solving problems and doing tasks.

Our thoughts affect the result that we get! Thus,

mindset change is important to effect changes!
8
 The Fifth Discipline, Peter Senge (1990)

Through learning (mindset change), we:

• Re-create ourselves;
• Become able to do things we never were able to do before;
• Re-perceive the world and our relationship to it;
• Extend our capacity to create, to be part of the generative process of life
Systems Thinking - The Fifth Discipline that integrates the other four
https://www.youtube.com/watch?v=MQMRMAmT2gg 9
 Mental Models
• Our mental models determine what we see and what we do
not see. They are the symbols that we use to mentally process
the environment in which we function. Mental models are so
powerful - because they affect what we see
o Conflict with deeply held internal images of how the world works
o Mental models determine how we take action
For example, assumptions can be dangerous. Accidents can happen
when people assume that safety measures have been put in place or
that someone else is supposed to be responsible for safety. Ensuring
safety will require the right mindset and safe behavior at all times.
Everyone needs to take personal responsibility for their own safety.

Mental models are deeply ingrained assumptions,

generalizations or even pictures or images that influence
how we understand the world and take action.
10
 Personal Mastery
• Organizations learn only through individuals who learn
• Learning to expand our personal ability to produce the results
we most desire by creating a personal vision of who we want to
be; learning to see the world from a creative perspective which
encourages others to develop themselves.
• The essence of Personal Mastery is learning to generate and
sustain creative tension in our lives.
• Individual learning does not guarantee organizational learning,
but without it no organizational learning can occur
• Personal Vision
Personal mastery is a discipline of continually clarifying and
deepening our personal vision, of focusing our energies, of
developing patience, and of seeing reality objectively.
11
 Team Learning

• Team learning is the process of aligning and developing

the capacity of a team to create the results that
members truly desire.

Team Learning is about learning together to develop group

intelligence and ability greater than the sum of individual
members & abilities.

12
 Shared Vision

• A shared vision is a vision that many people are truly committed to and
it reflects their own personal vision
• Helps to establish primary goals and provides a rudder to keep the
learning process on course when stresses develop

Shared Vision is about building a practice of unearthing

shared pictures of the future that foster genuine
commitment and enrollment rather than compliance.
13
 A Model and Process for Change

Creative Tension:
• What do we want?
• What do we have?
• Why do we have what we have?
• What do we have to keep, build, destroy to get what we want?
• What actions/projects do we need to initiate?
14
 Systems Thinking – Iceberg Analogy

React Events

Respond Patterns

Design Structure

• An issue is often presented to us, in the form of events and patterns.

• To get to the root of any issue, we should uncover the underlying
structures which form the patterns and events, that are often only
visible to us.
https://www.youtube.com/watch?v=9I5YvLm5KXI
15
 HAIR:
• Helicopter Vision
• Analytical Power
• Imagination
• Realism

Iceberg … seeing what’s

below the surface

16
The basis of systems thinking is the holistic approach, of
seeing the system as a whole, of seeing the forest rather
than the trees.

17
 What is an “Event”?
1. An Event is an occurrence at some moment in time.

2. We’re hung up on events rather than their causes or

how they fit into a larger pattern.

3. We cannot continue to react to events; rather we

must anticipate and shape them.

4. Solutions that address events are short-lives

because they do not address the fundamental
structure that caused the event

18
 What are “Patterns” (Trends)?
1. Patterns are changes in events over time.
2. Patterns allow us to understand the systemic
structure that drives that pattern.
3. In a pattern, we begin to see how a series of events
are inter-related and begin thinking about what
caused them.
4. To anticipate events and ultimately change a pattern,
we need to move to the level of structure.

19
 What is a “Structure”?
1. A structure is the way system components are interrelated,
i.e. the organization of a system.
2. A system’s structure give rise to events and patterns
(trends).
3. Although systems are built on structures, they are invisible.
4. The structure holds the key to lasting change because
actions taken at the structural level are creative and
influence the future.
5. Know when to address a problem at the event, pattern or
structural level or a combination of the three.

20
 Seven Thinking Skills of a Systems Thinker by Barry Richmond
Systems Thinking skill Contrasts with…
Dynamic Thinking – Focusing on patterns of Static Thinking – Focusing on specific events
behavior (trends) over time
System-as-Cause Thinking – Choosing to System-as-Effect Thinking – Choosing to
focus on the system within the organization’s focus on forces outside the organization’s control
control as responsible for performance issues as generating the performance issues (creating
“victimitis”)
Forest Thinking – Taking the 30,000 foot view Tree-by-tree Thinking – Focusing on the
of the system details, often getting lost in spreadsheets!
Operational Thinking – Looking for causality Factors Thinking – Developing a list of factors
(How is this behavior generated?) associated/correlated with the behavior
Closed-loop (Feedback) Thinking – Straight-line Thinking – Believing causality is
Understanding the feedback and ongoing process a one-way, linear relationship
responsible for behavior
Qualitative Thinking – Understanding how to Quantitative Thinking – Including only those
represent non-physical, immeasurable variables in variables believed measurable
analysis Scientific
Scientific Thinking – Building the most useful, Proving Truth Thinking – Looking for “The
entertainable theory of causality Answer”
21
 State Transition Diagram: The Blame Game

OK: Beginning or neutral state
Injured: Contributes to our stress
Blaming: Finds someone to blame
Vengeful: Revengeful passions
Causes Known: Identify causes and take
effective corrective actions.
Loss Mitigated: Take preventions against
similar problems from occurring.
22
 Shifting the Burden

• An underlying problem generates symptoms that

demand attention.

• But the underlying problem is obscure or costly to

confront.

• So people shift the burden to other solutions that

address the symptoms.

23
MURPHY’S LAW
• Complacency
• The BELIEF:
– It will never happen to me …

• The LAW:
– If something can go wrong … It will …

The Original Murphy's Law states:

"If there are two or more ways to do something, and one of
those can result in catastrophe, then someone will do it.“
Edward A. Murphy

24
To Err is Human… Cicero : 106 – 46 BCE
Although errors are inherent in people, accidents are seldom attributed to any
single person.

Maintenance errors primarily reside in latency within task and/or situational

factors in a specific context and emerge as consequences of mismanaging
compromises between production and safety goals.

The compromise between production and safety is a complex and delicate

balance and humans are generally very effective in applying the right
mechanisms to successfully achieve it, hence the extraordinary safety record
of many high consequence industries.

Humans do, however, occasionally mismanage task and/or situational factors

and fail in balancing the compromise, thus contributing to safety breakdowns.

25
 James Reason’s Swiss Cheese Model of Accident Causation

• The Swiss Cheese model of accident investigation is

based on the premise that an accident is not caused by
a single error or event.

• There is usually a series of errors which managed to

break through the defences in an organization.

• These defences include Regulations, Design and

Manufacture Processes, SOP, Training and finally the
Operator (see diagram in next page).

26
James Reason’s Swiss Cheese Model of Accident Causation

https://www.youtube.com/watch?v=GlTt9kJwSbM
27
Two SMRT staff killed by an oncoming train on 22 Mar 2016

28
 A VITAL safety protection measure - where the speed limit on the affected track
sector is set to 0 km/h before a work team is allowed on it, so that no train can
enter on automated mode - was not applied on March 22, 2016, "directly
causing" the accident that killed two SMRT staff.
Said SMRT: "Before a work team is allowed onto the track, protection measures
must be applied. This includes code setting the speed limit on the affected 1
track sector to 0 km/h so that no train can enter on automated mode, and
2 deploying watchmen to look out for approaching trains and provide early
warning to the work team. 3
"The Accident Review Panel determined that this vital safety protection
measure was not applied and that the effectiveness of such protection before
entry into the work site was not ensured as required under existing procedure,
directly causing the accident. There were also other factors identified as areas
for improvement, namely track access management controls, communication
protocols and track vigilance by various parties.
"The Accident Review Panel has concluded that while existing safety protection
mechanisms are adequate, and current operating procedures continue to be
relevant and applicable, these can be improved for greater clarity and ease of
ground implementation.”
SMRT Press Release : 25 Apr 2016
29
What’s Wrong with this?

Eunos Bus Terminal – Jan 2016

Colors mismatch can induce errors

30
 HUMAN FACTORS
The study of human capabilities and limitations in the
workplace.
Human Error
a) Sources of error
b) Types of error.
Managing Human Factors
a) Error Management
b) Human Resource Management
Optimizing Human and System Relationship to improve
Safety, Quality and Efficiency.

31
 The Need to focus on Human Factors
➢ To enhance awareness of individual and
organizational human factors issues that may affect
safety.
➢ To acquire human factors skills, such as
communication, effective teamwork, task
management, situational awareness etc..
➢ Such training in Human Factor will make a positive
impact on the safety and efficiency of maintenance
operations, and ultimately encourage a positive
attitude towards safety whilst discouraging unsafe
behaviour and practices.
32
Note that some accidents can be attributed to both, machine failures and human errors

33
 Attributes of Human Factors
• Human physiology
Mechanical, physical and biochemical functions of
humans in good health
• Anthropometrics
The scientific study of measurements of the human body
• Psychology
Perception, cognition, memory, social interaction, error
• Work place design
• Environmental conditions
• Human-machine interface
• the length of a man's outspread arms (arm span) is equal to his height
• the distance from the hairline to the bottom of the chin is one-tenth of a man's height
• the distance from the top of the head to the bottom of the chin is one-eighth of a man's height
34
The data for these decisions are available from anthropometry and
biomechanics.

Vitruvian Man

Anthropometry concerned with the Biomechanics is the science concerned

comparative study of human evolution, with the internal and external forces
variation, and classification especially acting on the human body and the
through measurement and observation. effects produced by these forces.
35
Psychology
• Input characteristics: Humans have been provided with a
sensory system for collecting information from the world
around them, enabling them to respond to external events
and to carry out the required task.
• But all senses are subject to degradation for various reasons.
The sources of knowledge here are physiology, psychology
and biology.
• Information processing: These human capabilities can have
limitations. Poor manuals, instrumentation and warning
system design has frequently resulted from a failure to take
into account the capabilities and limitations of the human
information processing system.
• Short and long-term memories are involved, as well as
motivation and stress. Psychology provides the source of
background knowledge.
36
Software Procedures, manuals, task cards, AMM, rules
and regulations, training, computer software,
etc
Hardware Aircraft, tooling, ground equipment, access
within the aircraft, ergonomics, etc
Environment The situation in which the S-H-L system must
function – noise, lighting, temperature, hangar
space, economic climate of the industry, etc
Liveware Human – YOU – including colleagues,
managers, supervisors, domestic pressures, etc
In this model the match or mismatch of the blocks (interface) is as important
as the characteristics of the blocks themselves. A mismatch can be a source of
human error.

37
Error Chain
In the examples, the
accident or incident
could be avoided if
things were done
differently. They
involved a series of
human factors
problems which
formed an error chain.

Engineering staff members, progressing towards a mishap can interrupt

that sequence of events such that it would not occur. Aircraft maintenance
engineer could identify where the vulnerable areas might be within the
maintenance ‘link’, which should prevent the error chain reaching a
catastrophic conclusion.
The Error Chain. Source: Boeing
https://www.youtube.com/watch?v=qnWGuOfeZi4
38
Human Error
“Error will be taken as a generic term to
encompass all those occasions in which a
planned sequence of mental or physical
activities fails to achieve its intended outcome,
and when these failures cannot be attributed
to the intervention of some chance agency”.

James Reason

39
Human failure taxonomy

40
Slips, Lapses and Mistakes
James Reason has classified errors based on the intention.

41
 The three kind of errors are slips, lapses and mistakes.
• Slips can be thought of as actions not carried out as intended or
planned, e.g. A classic example is an aircraft’s crew that becomes so
fixated on trouble-shooting a burned out warning light that they do not
notice their fatal descent into the terrain. This is attention failures (slips).
• Lapses are missed actions and omissions. Memory failures (lapses)
often appear as omitted items in a checklist, place losing, or forgotten
intentions. E.g. when under stress during in-flight emergencies, critical
steps in emergency procedures can be missed. However, even when not
particularly stressed, individuals have forgotten to set the flaps on
approach or lower the landing gear.
• Mistakes are a specific type of error brought about by a faulty
plan/intention. In the case of planning failures (mistakes), the person
did what he/she intended to do, but it did not work. The goal or plan
was wrong. This type of error is referred to as a mistake.

42
• Violations sometimes appear to be human errors, but they differ
from slips, lapses and mistakes because they are deliberate ‘illegal’
actions, i.e. somebody did something knowing it to be against the
rules (e.g. deliberately failing to follow proper procedures).

By distinguishing errors from violations, companies can develop a “Just

Culture” to assign appropriate culpability to employee & management.

43