Causation, levels of analysis and explanation in systems ergonomics – A closer look at the UK NHS Morecambe Bay investigation

This paper extends an earlier examination of the concept of ‘mesoergonomics’ (Karsh et al., 2014) and its application to Human Factors/Ergonomics (HFE). Karsh et al. (2014) developed a framework for mesoergonomic inquiry based on a set of steps and questions, the purpose of which was to encourage researchers to cross system levels in the studies (e.g., organisation-group-individual levels of analysis) and to explore alternative causal mechanisms and relationships within their data. The present paper further develops the framework and draws on previous work across a diverse range of sources (safety science, systems theory, the sociology of disaster and ethology) which has examined the subject of accident causation, levels of analysis and explanatory factors contributing to system failure. The outcomes from this exercise are a revised framework which seeks to explore what we term ‘isomorphisms’ and includes questions covering: (a) how internal isomorphisms develop or evolve within the system; and, (b) how these isomorphisms are shaped by cultural, professional and other forms of external influence. The workings of the revised framework are illustrated through using the example of the UK NHS Morecambe Bay Investigation (Kirkup, 2015). The paper concludes with a summary of ways forward for the framework, as well as new directions for theory within systems ergonomics/human factors.