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 Systems Thinking
in Practice
Applications of the Event Analysis
of Systemic Teamwork Method
 Transportation Human Factors: Aerospace,
Aviation, Maritime, Rail, and Road Series
Series Editor
Professor Neville A Stanton
University of Southampton, UK

Automobile Automation
Distributed Cognition on the Road
Victoria A. Banks, Neville A. Stanton

Eco-Driving
From Strategies to Interfaces
Rich C. McIlroy, Neville A. Stanton

Systems Thinking in Practice

Applications of the Event Analysis of Systemic Teamwork Method
Neville A. Stanton, Paul M. Salmon, Guy H. Walker

For more information about this series, please visit: https://www.crcpress.com/­

Transportation-Human-Factors/book-series/CRCTRNHUMFACAER
 Systems Thinking
in Practice
Applications of the Event Analysis
of Systemic Teamwork Method

Neville A. Stanton
Paul M. Salmon
Guy H. Walker
CRC Press
Taylor & Francis Group
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Library of Congress Cataloging‑ in‑ Publication Data

Names: Stanton, Neville A. (Neville Anthony), 1960- author. | Salmon, Paul

M., author. | Walker, Guy, author.
Title: Systems thinking in practice : applications of the Event Analysis of
Systemic Teamwork method / Neville A. Stanton, Paul Salmon, and Guy Walker.
Description: First edition. | Boca Raton, FL : CRC Press/Taylor & Francis
Group, 2018. | Series: Transportation human factors: Aerospace, aviation,
maritime, rail, and road series | Includes bibliographical references and
index.
Identifiers: LCCN 2018026593| ISBN 9781138097872 (hardback : alk. paper) |
ISBN 9781315104683 (ebook)
Subjects: LCSH: Systems engineering. | Teams in the workplace.
Classification: LCC TA168 .S68 2018 | DDC 658.4/022011--dc23
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Contents
Preface.................................................................................................................... xiii
Authors....................................................................................................................xvii
Board Members and Affiliations.............................................................................xix

Section I  Overview of EAST

Chapter 1 The Event Analysis of Systemic Teamwork (EAST) Method............... 3

With Nicholas J. Stevens
Background and Applications...............................................................4
Domain of Application..........................................................................5
Application in Land Use Planning and Urban Design (LUP & UD)...... 5
Procedure and Advice...........................................................................5
Step 1: Define Analysis Aims........................................................... 5
Step 2: Define the Task/System Under Analysis.............................. 6
Step 3: Data Collection..................................................................... 6
Step 4: Transcribe Data....................................................................6
Step 5: Construct Task Network.......................................................6
Step 6: Conduct Social Network Analysis........................................8
Step 7: Construct Information Networks.......................................... 8
Step 8: Construct Composite Networks............................................ 8
Step 9: Analyse Networks................................................................8
Advantages............................................................................................9
Disadvantages...................................................................................... 10
Related Methods.................................................................................. 10
Approximate Training and Application Times................................... 10
Reliability and Validity....................................................................... 10
Flowchart............................................................................................. 10
Tools Needed....................................................................................... 11
Example............................................................................................... 11
References........................................................................................... 15

Section II  Applications of EAST

Chapter 2 EAST in Air Traffic Control............................................................... 19

With Chris Baber, Linda Wells, Huw Gibson and Daniel P. Jenkins
Introduction......................................................................................... 19
Command and Control................................................................... 19
v
vi Contents

Distributed Cognition..................................................................... 19
Distributed Situation Awareness....................................................20
Beyond Ethnography...................................................................... 21
The Air Traffic Control Work Setting................................................. 23
Charts and Standard Routes........................................................... 23
Flight Data Strip............................................................................. 23
Flight Data Strip Bay...................................................................... 23
Radar Display................................................................................. 23
Aircraft Call Signs.........................................................................24
Communications.............................................................................24
Distributed Cognition Methodology: The Importance of Methods........ 24
Descriptive vs. Formative Methods................................................24
Method Integration.........................................................................25
Air Traffic Control Scenarios..............................................................25
Applying the Method......................................................................26
Representing Distributed Cognition...............................................26
Task Networks................................................................................26
Social Networks.............................................................................. 27
Propositional Networks..................................................................28
Application to Air Traffic Control......................................................28
Analysis of Agents in the Distributed Cognition System...............28
Facilitating Technology.................................................................. 31
Control Architecture....................................................................... 31
Systemic Situational Awareness..................................................... 33
Temporal Aspects of Command and Control in Air Traffic
Control............................................................................................ 35
Conclusions......................................................................................... 35
Acknowledgements............................................................................. 36
References........................................................................................... 36

Chapter 3 EAST in Military Command and Control.......................................... 39

With Rebecca Stewart, Daniel P. Jenkins, Linda Wells and
Chris Baber
Introduction......................................................................................... 39
Description of Command and Control Scenarios............................... 39
Army Land Warfare and the Combat Estimate.............................. 39
Data Collection...............................................................................40
Description of the East Method.......................................................... 41
The Importance of Methods........................................................... 41
Descriptive vs. Formative Methods................................................ 41
Method Integration......................................................................... 42
Situational Awareness.................................................................... 42
Theoretical Basis............................................................................44
Findings...............................................................................................44
Contents vii

Coordination Demand Analysis (CDA)..........................................44

Communications Usage Diagram (CUD).......................................46
Advantages and Disadvantages of Existing
Communications Media............................................................. 48
Social Network Analysis (SNA)..................................................... 48
Activity Stereotypes.................................................................. 52
Facilitation of Network Links.................................................... 52
Calculation of Social Network Metrics..................................... 53
Operation Sequence Diagrams (OSD)............................................ 54
Propositional Networks (PN)......................................................... 56
Conclusions......................................................................................... 58
Acknowledgements............................................................................. 61
References........................................................................................... 61

Chapter 4 EAST in Energy Distribution Operations........................................... 65

With Daniel P. Jenkins, Chris Baber and Richard McMaster
Introduction......................................................................................... 65
Example Case Study: A Human Factors Analysis of Civilian
Command and Control................................................................... 67
Scenario 1: Switching Operations Scenario (Barking).............. 68
Scenario 2: Maintenance Scenario (Tottenham)....................... 68
Methodology....................................................................................... 69
Design............................................................................................. 69
Participants..................................................................................... 69
Materials......................................................................................... 70
Procedure........................................................................................ 71
Results................................................................................................. 72
Task Networks................................................................................ 72
Social Networks.............................................................................. 72
Information Networks.................................................................... 73
Additional EAST Analyses............................................................ 74
Summary............................................................................................. 77
References........................................................................................... 81

Chapter 5 EAST in a Submarine Control Room.................................................. 83

Analysing Distributed Cognition........................................................ 83
System Properties of EAST................................................................. 85
Data Collection and Analysis.............................................................. 86
Task Network Analysis........................................................................ 89
Social Network Analysis (SNA)..........................................................92
Information Network Analysis............................................................ 93
Combining Network Models............................................................... 95
Task and Social Networks..............................................................97
viii Contents

Information and Social Networks..................................................99

Information and Task Networks................................................... 100
Combined Task, Social and Information Networks..................... 100
Summary and Conclusions................................................................ 100
Acknowledgements........................................................................... 106
References......................................................................................... 106

Chapter 6 EAST in Railway Maintenance......................................................... 109

With Huw Gibson and Chris Baber
Introduction....................................................................................... 109
Development of the East Methodology............................................. 110
Layer 1 – Data Collection Methods.............................................. 111
Layer 2 – Analysis Methods......................................................... 112
Hierarchical Task Analysis (HTA).......................................... 112
Coordination Demand Analysis (CDA)................................... 114
Communications Usage Diagram (CUD)................................ 115
Social Network Analysis (SNA).............................................. 115
Layer 3 – Representational Methods............................................ 115
Operation Sequence Diagram (OSD)...................................... 116
Propositional Network (PN).................................................... 116
Summary of Methods................................................................... 117
Structure of EAST Methodology................................................. 118
Procedure.......................................................................................... 119
Application of the Method to Live Data........................................... 119
Background................................................................................... 119
Scenario 1 – Planned Maintenance Activities......................... 121
Scenario 2 – Emergency Engineering Work........................... 122
Scenario 3 – Ending a Track Possession................................. 122
Results and Discussion...................................................................... 122
Analysis Methods......................................................................... 122
Task Networks......................................................................... 122
CDA......................................................................................... 124
CUD......................................................................................... 125
SNA......................................................................................... 126
Representational Methods............................................................ 127
Scenario Process Charts (OSD)............................................... 127
Propositional Networks (PN)................................................... 127
Summary...................................................................................... 129
Conclusions....................................................................................... 129
Further Insights............................................................................ 129
Wider Context............................................................................... 131
Acknowledgements........................................................................... 131
References......................................................................................... 131
Contents ix

Chapter 7 EAST at Road Intersections.............................................................. 135

With Michael G. Lenné and J. Ashleigh Filtness
Statement of Relevance..................................................................... 135
Introduction....................................................................................... 135
EAST Intersection Case Study..................................................... 136
Methodology..................................................................................... 138
Design........................................................................................... 138
Participants................................................................................... 138
Materials....................................................................................... 138
Procedure...................................................................................... 139
Results............................................................................................... 141
Task Networks.............................................................................. 141
Social Networks............................................................................ 144
Situation Awareness Networks..................................................... 147
Discussion......................................................................................... 151
Reducing Complexity................................................................... 151
Performance Limitations.............................................................. 152
System Redesign........................................................................... 153
Conclusion......................................................................................... 154
References......................................................................................... 154

Chapter 8 EAST in Elite Women’s Cycling Teams........................................... 157

With Clare Dallat and Amanda Clacy
Introduction....................................................................................... 157
Elite Women’s Cycling................................................................. 158
Event Analysis of Systemic Teamwork........................................ 159
EAST Analysis of Elite Women’s Cycling................................... 159
Methods............................................................................................. 159
Participants................................................................................... 159
Materials....................................................................................... 160
Procedure...................................................................................... 160
Results............................................................................................... 161
Task Network................................................................................ 161
Social Network............................................................................. 162
Situation Awareness Network....................................................... 162
Conclusion......................................................................................... 163
What Does the Analysis Tell Us About DSA and Teamwork
in Elite Women’s Cycling Teams?................................................ 163
What Are the Implications for Optimising Performance in
Elite Women’s Cycling Teams?.................................................... 165
What Are the Implications for Future EAST Applications in
Elite Sport?................................................................................... 166
References......................................................................................... 166
x Contents

Chapter 9 EAST in Automated Driving Systems.............................................. 169

With Victoria A. Banks
Introduction....................................................................................... 169
Levels of Automation and the Role of the Driver......................... 169
Method.............................................................................................. 171
Results............................................................................................... 173
Task Networks.............................................................................. 173
Social Networks............................................................................ 175
Information Networks.................................................................. 179
Discussion......................................................................................... 181
Conclusions....................................................................................... 182
Acknowledgements........................................................................... 183
References......................................................................................... 183

Chapter 10 EAST in Future Road Transportation Systems................................. 187

With Victoria A. Banks, Gary Burnett and Setia Hermawati
Introduction....................................................................................... 187
Method.............................................................................................. 188
Results............................................................................................... 190
Identification of System Agents.................................................... 190
Task Networks.............................................................................. 190
Social Networks............................................................................ 193
Information Networks.................................................................. 196
Discussion......................................................................................... 199
Conclusions....................................................................................... 201
References......................................................................................... 201

Section III  Future Developments in EAST

Chapter 11 STAMPING on EAST: Adding a Control Network to EAST

to Examine the Safety Controls in the Railway Level Crossing
System Lifecycle ..............................................................................207
With Gemma J. M. Read, Natassia Goode, Eryn Grant, Clare
Dallat, Tony Carden and Anjum Naweed
Introduction.......................................................................................207
Research Context: Railway Level Crossings.....................................208
Part 1: Integrating EAST and STAMP.............................................209
STAMP and Control Theory........................................................209
Integrating EAST and STAMP: A Network of Controls............. 212
Part 2: Applying the Integrated Method to RLX Safety
Management...................................................................................... 213
Contents xi

Methodology................................................................................. 213
Data Inputs............................................................................... 213
EAST Network Development.................................................. 213
Network Analysis.................................................................... 214
Results............................................................................................... 216
Task Network................................................................................ 216
Social Network............................................................................. 216
Information Network.................................................................... 216
Control Network........................................................................... 219
Discussion..................................................................................... 219
Implications for Railway Level Crossing Safety
Management................................................................................. 223
Conclusion......................................................................................... 223
References.........................................................................................224

Chapter 12 The EAST ‘ Broken-Links’ Approach: Assessing Risk in

Sociotechnical Systems..................................................................... 227
With Catherine Harvey
Introduction....................................................................................... 227
Case Study of Hawk Missile Simulation Training............................ 229
Analysis of Networks........................................................................ 232
Results............................................................................................... 233
Social Network............................................................................. 233
Task Network................................................................................ 234
Information Network.................................................................... 235
Broken-Links Analysis...................................................................... 237
Discussion......................................................................................... 241
Conclusions.......................................................................................246
Acknowledgements...........................................................................246
References .........................................................................................246

Chapter 13 From CWA to SNA: Modelling Future Flight Decks....................... 251

With Don Harris and Alison Starr
Introduction....................................................................................... 251
Design Approach............................................................................... 254
Aircraft Component..................................................................... 254
Ground-Based Component........................................................... 255
System ‘Mirror’............................................................................ 256
Modelling and Analysis of System Configurations........................... 256
Cognitive Work Analysis (CWA)................................................. 258
Work Domain Analysis (WDA)................................................... 258
Functional Purposes..................................................................... 258
Values and Priority Measures....................................................... 259
xii Contents

Physical Objects........................................................................... 259

Object-Related Processes.............................................................260
Purpose-Related Functions...........................................................260
Control Task Analysis (ConTA)................................................... 261
Social Organisational Cooperation Analysis – Contextual
Activity Template (SOCA-CAT).................................................. 262
Social Network Analysis.............................................................. 263
Conclusions....................................................................................... 270
References......................................................................................... 271

Chapter 14 Future Directions for the Event Analysis of Systemic Teamwork........275

Introduction....................................................................................... 275
Normal Performance as a Cause of Accidents.................................. 275
Accident Prediction........................................................................... 278
A Systems Approach to Prediction............................................... 279
East and Accident Prediction....................................................... 279
Migration towards Safety Boundaries...............................................280
Mapping Migration....................................................................... 281
Systems Concepts.............................................................................. 281
Human Factors and Ergonomics Methods in Design........................ 282
Conclusions....................................................................................... 285
References......................................................................................... 287
Index....................................................................................................................... 291
Preface
This book has arisen from the desire to share our insights into the practical applica-
tion of the Event Analysis of Systemic Teamwork (EAST) framework. Over the past
decade, we have applied EAST in many domains and have been impressed by the
insights that the products of the analysis afford. EAST offers a systemic and system-
atic approach to the analysis, design and evaluation of sociotechnical systems. As a
formative method, we have used it to design new concepts of operations, new teams
and new ways of working. As a summative method, we have used it to gain new
insights into existing systems and current ways of working.
The EAST method was initially developed for a programme of research into
command and control funded by the UK Ministry of Defence called the Human
Factors Integration Defence Technology Centre. This research began in 2003 and
ended in 2012.
The total funding was for £30 million over 10 years, and one of our projects was
to provide Human Factors advice for new networked architectures for command and
control. The idea was that potentially all military systems across all of the forces (from
the infantry soldier to the moving platforms [on land, in the air and at sea] to the joint
operations headquarters) could be connected like the World Wide Web is for civilian
activities.
This kind of connectivity meant we had to look at command and control in a
completely new way. Rather than develop completely new methods, we developed
EAST by integrating existing methods, as is explained in this book. Prof Chris Baber
and I decided to use network methods to investigate these command and control
networks. This began with investigations into both civilian and military examples
of command and control, some of which are presented in this book. The approach
has developed into the EAST method as we know it today. Over the years, we have
developed and refined the approach. What we particularly like about the network
methods is that they are both scalable and systemic in nature. We can analyse the
networks both qualitatively and quantitatively (using network statistics, as demon-
strated in this book).
We imagine people will approach this book with different purposes. For those
new to the EAST approach, we advise reading Chapter 1 and then finding a chap-
ter with your domain of interest. For those familiar with EAST, go straight to
the chapters that are of interest. For researchers and those keen on extending
the EAST approach, the final section of chapters on developments and future
directions will be of most interest. Each of the chapters is intended to be read
as a stand-alone article, so there is some inevitable repetition on the overview
of EAST (although different emphases and approaches to the method are taken).
Experts in EAST can skip over those sections. For those who use EAST and find it
useful in their work, we say, welcome to the tribe of happy EASTers. That EASTer
tribe already comprises the authors in this book, and we are aware of other groups
using EAST around the world. All of the chapters were led by one or more of the
lead authors of the book with the exception of Chapters 9 and 10, which were both

xiii
xiv Preface

led by Victoria Banks. We are grateful for the contributions and insights from our
co-authors and the progress that has been made with the method since its original
conception.
The EAST development journey is not at the end yet. There have been recent
developments that have extending the use of EAST. EAST, as a systems method, has
fared well, as systems approaches are very much in favour in the Ergonomics and
Human Factors world. We have had some successes linking EAST to other systems
methods, such as Systems Theoretic Accident Model and Process |(STAMP) and
Cognitive Work Analysis (CWA). We have also used EAST in formative ways to pre-
dict system network resilience. The journey does not end here, however, and we are
sure that we and others will continue to develop and extend the approach and apply
it to even more domains of application.
Neville A. Stanton
Professor of Human Factors Engineering
University of Southampton

RECOMMENDED FURTHER READING ON EVENT

ANALYSIS OF SYSTEMIC TEAMWORK
Salmon, P. M., Read, G. J. M., Goode, N., Grant, E., Dallat, C., Carden, T., Naweed, A.,
Walker, G. H. and Stanton, N. A. (2018). STAMP goes EAST: Integrating ergonomics
methods for the analysis of railway level crossing safety management. Safety Science:
doi.org/10.1016/j.ssci.2018.02.014.
Stanton, N. A. and Roberts, A. P. J. (2018). Examining task, social and information networks
in submarine command and control. IEEE Transactions on Human–Machine Systems,
doi: 10.1109/THMS.2017.2720659. (in press).
Banks, V. A. and Stanton, N. A. (2018). Analysis of driver roles: Modelling the changing
role of the driver in automated driving systems using EAST. Theoretical Issues in
Ergonomics Science, (in press).
Roberts, A. P. J, Stanton, N. A. and Fay, D. T. (2018). Go Deeper, Go Deeper: Understanding
submarine command and control during the completion of dived tracking operations.
Applied Ergonomics, 69, 162–175.
Banks, V. A., Stanton, N. A., Burnett, G. and Hermawati, S. (2018). Distributed Cognition
on the road: Using EAST to explore future road transportation systems. Applied
Ergonomics, 68, 258–266.
Roberts, A. P. J, Stanton, N. A. and Fay, D. T. (2017). Land Ahoy! – Understanding submarine
command and control during the completion of inshore operations. Human Factors,
59(8), 1263–1288.
Stanton, N. A., Roberts, A. P. J. and Fay, D. T. (2017). Up periscope: Understanding subma-
rine command and control teamwork during a simulated return to periscope depth.
Cognition, Technology and Work, 19(2–3), 399–417.
Stanton, N. A. and Harvey, C. (2017). Beyond human error taxonomies in assessment of risk
in sociotechnical systems: A new paradigm with the EAST ‘broken-links’ approach.
Ergonomics, 60(2), 221–233.
Stanton, N. A., Salmon, P. M., Walker, G. H., Salas, E. and Hancock, P. A. (2017). State-
of-science: Situation awareness in individuals, teams and systems. Ergonomics, 60(4),
449–466.
Plant, K. L and Stanton, N. A. (2016). Distributed cognition in Search and Rescue: Loosely
coupled tasks and tightly coupled roles. Ergonomics, 59(10), 1353–1376.
Preface xv

Sorensen, L. J. and Stanton, N. A. (2016). Keeping it together: The role of transactional situ-
ation awareness in team performance. International Journal of Industrial Ergonomics,
53, 267–273.
Salmon, P. M., Lenné, M. G., Walker, G. H., Stanton, N. A. and Filtness, A. (2014). Using the
Event Analysis of Systemic Teamwork (EAST) to explore conflicts between different
road user groups when making right hand turns at urban intersections, Ergonomics,
57(11), 1628–1642.
Salmon, P., Lenné, M., Walker, G. H., Stanton, N. A. and Filtness, A. (2014). Exploring
schema-driven differences in situation awareness across road users: An on-road
study of driver, cyclist and motorcyclist situation awareness. Ergonomics, 57(2),
191–209.
Stanton, N. A. (2014). Representing distributed cognition in complex systems: How a subma-
rine returns to periscope depth. Ergonomics, 57(3), 403–418.
Walker, G. H., Stanton, N. A., Baber, C., Wells, L., Gibson, H., Salmon, P. M. and Jenkins,
D. P. (2010). From ethnography to the EAST method: A tractable approach for repre-
senting distributed cognition in air traffic control. Ergonomics, 53(2), 184–197.
Walker, G. H., Stanton, N. A., Salmon, P. M., Jenkins, D., Stewart, R. and Wells, L. (2009).
Using an integrated methods approach to analyse the emergent properties of military
command and control. Applied Ergonomics, 40(4) 636–647.
Stanton, N. A., Salmon, P. M., Walker, G. H., and Jenkins, D. P. (2009). Genotype and pheno-
type schema and their role in distributed situation awareness in collaborative systems.
Theoretical Issues in Ergonomics Science, 10(1), 43–68.
Stanton, N. A., Salmon, P. M., Walker, G. H., and Jenkins, D. P. (2009). Genotype and phe-
notype schemata as models of situation awareness in dynamic command and control
teams. International Journal of Industrial Ergonomics, 39(3), 480–489.
Salmon, P. M., Stanton, N. A., Walker, G. H., Jenkins, D. P., Baber, C., and McMaster, R.
(2008). Representing situation awareness in collaborative systems: A case study in the
energy distribution domain. Ergonomics, 51(3), 367–384.
Stewart, R., Stanton, N. A., Harris, D., Baber, C., Salmon, P., Mock, M., Tatlock, K., Wells, L.
and Kay, A. (2008). Distributed situation awareness in an Airborne Warning and
Control System: Application of novel ergonomics methodology. Cognition, Technology
and Work, 10(3), 221–229.
Salmon, P. M., Stanton, N. A., Walker, G. H., Jenkins, D. P., Baber, C., and McMaster, R.
(2008). Representing situation awareness in collaborative systems: A case study in the
energy distribution domain. Ergonomics, 51(3), 367–384.
Walker, G. H., Gibson, H., Stanton, N. A., Baber, C., Salmon, P. and Green, D. (2006). Event
Analysis of Systemic Teamwork (EAST): A novel integration of ergonomics methods
to analyse C4i activity. Ergonomics, 49(12–13), 1345–1369.
Houghton, R. J., Baber, C., McMaster, R., Stanton, N. A., Salmon, P., Stewart, R. and
Walker, G. (2006). Command and control in emergency services operations: A social
network analysis. Ergonomics, 49(12–13), 1204–1225.
Stanton, N. A., Stewart, R., Harris, D., Houghton, R. J., Baber, C., McMaster, R., Salmon, P.,
Hoyle. G., Walker, G., Young. M. S. et al. (2006). Distributed situation awareness in
dynamic systems: Theoretical development and application of an ergonomics method-
ology. Ergonomics, 49(12–13), 1288–1311.

THERE ARE ALSO THESE BOOKS:

Stanton, N. A., Salmon, P. M., Walker, G. H., Baber, C. and Jenkins, D. (2005). Human
Factors Methods: A Practical Guide for Engineering and Design (first edition).
Ashgate: Aldershot.
xvi Preface

Stanton, N. A., Baber, C. and Harris, D. (2008). Modelling Command and Control: Event
Analysis of Systemic Teamwork. Ashgate: Aldershot.
Stanton, N. A., Salmon, P. M., Rafferty, L. A., Walker, G. H., Baber, C. and Jenkins, D.
(2013). Human Factors Methods: A Practical Guide for Engineering and Design (sec-
ond edition). Ashgate: Aldershot.
Authors
Professor Neville Stanton, PhD, DSc, is a chartered psychologist, chartered ergon-
omist and chartered engineer. He holds the Chair in Human Factors Engineering in
the Faculty of Engineering and the Environment at the University of Southampton
in the United Kingdom. He earned degrees in Psychology, Applied Psychology and
Human Factors and has worked at the Universities of Aston, Brunel, Cornell and
MIT. His research interests include modelling, predicting, analysing and evaluating
human performance in systems as well as designing the interfaces and interaction
between humans and technology. Professor Stanton has worked on the design of
automobiles, aircraft, ships and control rooms over the past 30 years on a variety
of automation projects. He has published 40 books and over 300 journal papers on
Ergonomics and Human Factors. In 1998, he was awarded the Institution of Electrical
Engineers Divisional Premium Award for research into System Safety. The Institute
of Ergonomics and Human Factors awarded him the Otto Edholm Medal in 2001, the
President’s Medal in 2008 and the Sir Frederic Bartlett Medal in 2012 for his contri-
butions to basic and applied ergonomics research. The Royal Aeronautical Society
awarded him and his colleagues the Hodgson Prize and Bronze Medal in 2006 for
research on design-induced, flight-deck error published in The Aeronautical Journal.
The University of Southampton awarded him a Doctor of Science in 2014 for his sus-
tained contribution to the development and validation of Human Factors methods.

Professor Paul Salmon holds a Chair in Human Factors and is creator and director
of the Centre for Human Factors and Sociotechnical Systems at the University of
the Sunshine Coast. He currently holds a prestigious Australian Research Council
Future Fellowship and has almost 15 years’ experience in applied Human Factors
research in a number of areas, including defence, transportation safety, sports and
outdoor recreation and disaster management. Professor Salmon currently leads
major research programmes in the areas of road and rail safety, identity theft and
cybersecurity and led outdoor recreation accidents. He has co-authored 14 books,
over 180 peer-reviewed journal articles and numerous conference articles and book
chapters. He has received various accolades for his contributions to research and
practice, including the Australian Human Factors and Ergonomics Societies 2016
Cumming Memorial medal, the UK Ergonomics Society’s Presidents Medal, the
Royal Aeronautical Society’s Hodgson Prize for best research and paper and the
University of the Sunshine Coast’s Vice Chancellor and President’s Medal for
Research Excellence. Professor Salmon’s current research interests relate to extend-
ing Human Factors and Sociotechnical Systems theory and methods to support the
optimisation of systems in many areas. Specific areas of focus include accident pre-
diction and analysis, systems thinking in transportation safety, the development of
systemic accident countermeasures, human factors in elite sports and cybersecurity.

Professor Guy Walker works within the Institute for Infrastructure and Environment
at Heriot-Watt University in Edinburgh. He lectures on Human Factors and is the

xvii
xviii Authors

author/co-author of over 100 peer-reviewed journal articles and 13 books. He and

his co-authors have been awarded the Institute for Ergonomics and Human Factors
President’s Medal for the practical application of Ergonomics theory and the Peter
Vulcan Prize for best research paper by the 2013 Australasian Road Safety Research
Conference. In 2011, he also won Heriot-Watt University’s Graduate’s Prize for inspi-
rational teaching. Prof Walker earned a BSc Honours degree in Psychology from the
University of Southampton and a PhD in Human Factors from Brunel University. His
research interests are wide ranging, spanning driver behaviour and the role of feed-
back in vehicles, using Human Factors methods to analyse black-box data recordings
and the application of sociotechnical systems theory to the design and evaluation
of civil engineering systems through to safety, risk and reliability. His research has
featured in the popular media, from national newspapers, TV and radio through to
an appearance on the Discovery Channel.
Board Members and Affiliations

Chris Baber Huw Gibson

School of Electronic, Electrical Human Factors Specialist
& Computing Engineering Rail Safety and Standards Board
University of Birmingham London, UK
Birmingham, UK
Natassia Goode
Victoria A. Banks Centre for Human Factors and
Human Factors Engineering Sociotechnical Systems
Transportation Research Group University of the Sunshine Coast
University of Southampton Queensland, Australia
Southampton, UK
Eryn Grant
Gary Burnett Centre for Human Factors and
Human Factors Research Group Sociotechnical Systems
University of Nottingham University of the Sunshine Coast
Nottingham, UK Queensland, Australia

Tony Carden Don Harris

Centre for Human Factors and Human Systems Integration Group
Sociotechnical Systems Coventry University
University of the Sunshine Coast Coventry, UK
Queensland, Australia
Catherine Harvey
Human Factors Research Group
Amanda Clacy
University of Nottingham
Centre for Human Factors and
Nottingham, UK
Sociotechnical Systems
University of the Sunshine Coast Setia Hermawati
Queensland, Australia Human Factors Research Group
University of Nottingham
Clare Dallat Nottingham, UK
Centre for Human Factors and
Sociotechnical Systems Daniel P. Jenkins
University of the Sunshine Coast DCA Design International Ltd
Queensland, Australia Warwick, UK

Ashleigh J. Filtness Michael G. Lenné  

Design School Accident Research Centre
Loughborough University Monash University, Clayton Campus
Loughborough, UK Victoria, Australia

xix
xx Board Members and Affiliations

Richard McMaster Alison Starr

Senior Human Factors Consultant The National Composites Centre
Abbott Risk Consulting (ARC) Ltd Bristol and Bath Science Park
London, UK Bristol, UK

Anjum Naweed Nicholas J. Stevens

Appleton Institute for Behavioural Science Centre for Human Factors and
Central Queensland University Sociotechnical Systems
Queensland, Australia University of the Sunshine Coast
Queensland, Australia
Gemma J. M. Read
Centre for Human Factors and Rebecca Stewart
Sociotechnical Systems Lockheed Martin
University of the Sunshine Coast Langstone Technology Park
Queensland, Australia Havant, UK

Paul M. Salmon Guy H. Walker

Centre for Human Factors and School of the Built Environment
Sociotechnical Systems Heriot-Watt University
University of the Sunshine Coast Edinburgh, UK
Queensland, Australia
Linda Wells
Neville A. Stanton BAE Systems
Human Factors Engineering Somerset, UK
Transportation Research Group
University of Southampton
Southampton, UK
Section I
Overview of EAST
 1 The Event Analysis of
Systemic Teamwork
(EAST) Method
With Nicholas J. Stevens

In this book, we describe a series of studies that apply the systems thinking approach
using the Event Analysis of Systemic Teamwork (EAST) method. Systems thinking
is a contemporary approach that has currency within the discipline of human fac-
tors. It aims to understand and improve safety and performance in complex socio-
technical systems. Human factors issues are increasingly being examined through
the systems thinking lens (Karsh et al. 2014; Salmon et al. 2017; Walker et al.
2017). In line with this, since the turn of the century, a range of Human Factors
methods have either been developed or have experienced a resurgence in popular-
ity. These include systems analysis frameworks, such as Cognitive Work Analysis
(CWA) (Vicente 1999) and EAST (Stanton et al. 2008); accident analysis methods,
such as AcciMap (Svendung and Rasmussen 2002), the Systems Theoretic Accident
Model and Processes (STAMP) (Leveson 2004), and the Functional Resonance
Analysis Method (FRAM) (Hollnagel 2012); and systems design methods, such as
the MacroErgonomic Analysis and Design method (MEAD) (Kleiner 2006) and the
Cognitive Work Analysis Design Toolkit (Read et al. 2016).
The aim of this book is to demonstrate how one of these methods, EAST, can be
used to provide in-depth analyses of performance and safety in complex sociotechni-
cal systems (STS). The systems thinking approach involves taking the overall system
as the unit of analysis, looking beyond individuals and considering the interactions
between humans and between humans and artefacts within a system. This view also
encompasses factors within the broader organisational, social or political system in
which behaviour takes place. Taking this perspective, behaviours emerge not from
the decisions or actions of individuals but from interactions between humans and
artefacts across the wider system. At the most basic level when examining STS, the
descriptive constructs of interest can be distilled down to simply

• Why: the goals of the system, sub-system[s] and actor[s]

• Who: the actors performing the activity, including humans and technologies
• When: when activities take place and which actors are associated with them
• Where: where activities and actors are physically located
• How: (how activities are performed and how actors communicate and col-
laborate to achieve goals).

3
4 Systems Thinking in Practice

To assist researchers and practitioners explore these constructs, EAST (Stanton

et al. 2013) offers a comprehensive framework for the design, evaluation and analysis
of complex sociotechnical systems. As well as offering a description of the activ-
ity performed within a particular system, the approach provides methods that can
be used to develop an in-depth analysis of the constraints that shape agent activ-
ity within the system. Sociotechnical systems scenarios are often so complex and
multi-faceted, and analysis requirements so diverse, that various methods need to
be applied as one method in isolation cannot cater for the scenario and analysis
requirements. Building on a long history and tradition of methods integration in
human factors research and practice (Stanton et al. 2005), EAST (Stanton et al. 2008,
2013) provides an integrated suite of methods for analysing the performance of com-
plex sociotechnical systems. The framework supports this by providing methods to
describe, analyse and integrate three network-based representations of activity: task,
social and information networks. An overview of the EAST method is provided in
the remainder of this introductory chapter.

BACKGROUND AND APPLICATIONS

EAST (Stanton et al. 2008) provides a framework of methods that allows system
performance to be comprehensively described and evaluated. Since its conception,
the framework has been applied in many domains, including land and naval warfare
(Stanton et al. 2006; Stanton 2014), aviation (Stewart et al. 2008), air traffic control
(Walker et al. 2010), road transport (Salmon et al. 2014a) the emergency services
(Houghton et al. 2008) and elite cycling (Salmon et al. 2017). Within this book, the
application areas covered include

• aviation (Chapters 2, 12 and 13)

• command and control (Chapters 3 and 5)
• energy distribution (Chapter 4)
• rail transportation (Chapters 6 and 11)
• road transportation (Chapters 7, 9 and 10) and
• sport (Chapter 8)

Underpinning the approach is the notion that distributed teamwork can be

meaningfully described via a ‘network of networks’ approach, shown in Figure
1.1. Specifically, three networks are considered: task, social and information net-
works. Task networks describe the goals and subsequent tasks being performed
within the system. Social networks analyse the organisation of the system (i.e.
communications structure) and the communications taking place between the
actors working in the team. Finally, information networks describe the informa-
tion and knowledge (situation awareness) that the different actors use and share
during task performance.
Recent applications of the framework have also adopted a composite network
analysis approach whereby the three networks are integrated to show the relation-
ships between tasks, social interactions and information (Stanton 2014).
The Event Analysis of Systemic Teamwork (EAST) Method 5

FIGURE 1.1 Network of networks approach.

DOMAIN OF APPLICATION
EAST is a generic approach that was developed originally for the analysis of
teamwork in sociotechnical systems, but it has since been used to provide analy-
ses at the micro (Salmon et al. 2014a), meso (Stanton 2014) and macro (Stanton
and Harvey 2017) levels of sociotechnical systems. As such, it can be used in any
domain in which social and technical elements are working together in pursuit
of a common goal. The case study presented in this chapter, used to demonstrate
EAST, is based on an application within the area of land use planning and in
urban design (Stevens et al., 2018).

APPLICATION IN LAND USE PLANNING

AND URBAN DESIGN (LUP & UD)
LUP & UD is most often a product of multi-disciplinary approaches to complex
environments and sociotechnical systems (Stevens et al. 2018). Our projects and pro-
cesses require different resources from a variety of participants over a range of time
frames. Whilst we may not always define these approaches as teamwork, the EAST
approach has the potential to offer critical insights into more effective and efficient
cooperative processes and project performance.

PROCEDURE AND ADVICE

Step 1: Define Analysis Aims
First, the aims of the analysis should be clearly defined so that appropriate scenarios
are used and relevant data are collected. In addition, not all components of the EAST
framework may be required, so it is important to clearly define the aims at this point
to ensure that the appropriate EAST methods are applied.
6 Systems Thinking in Practice

Step 2: Define the Task/System Under Analysis

Next, the task (or tasks) or scenario (or scenarios) under analysis should be clearly
defined. This is dependent upon the aims of the analysis and may include a range
of tasks or one task in particular. It is normally standard practice to develop a
Hierarchical Task Analysis (HTA) (see Stanton 2006) for the task under analysis
if sufficient data and subject matter expert (SME) access are available. This is use-
ful later on in the analysis and is also enlightening, allowing the analyst to gain an
understanding of the task before the observation and analysis begins.

Step 3: Data Collection

Once the aims of the analysis are clearly defined, the next step involves collect-
ing targeted data about the system and its behaviour. The specific data collected are
dependent on the analysis aims and the resources available; however, data collection
for EAST typically involves observations, concurrent verbal protocols, structured or
semi-structured interviews (e.g. the Critical Decision Method [CDM]; Klein et al.,
1989), walkthrough analysis and documentation review (e.g. incident reports, stan-
dard operating procedures).
The observation step is often the most important part of the EAST procedure.
Typically, a number of analysts are used to observe the system or scenario under
analysis. All activities involved in the scenario under analysis should be recorded
along an incident timeline, including a description of the activity undertaken, the
agents involved, any communications made between agents and the technology
involved. Additional notes should be made where required, including the purpose of
the activity observed; any tools, documents or instructions used to support activity;
the outcomes of activities; any errors made; and also any information that the agent
involved feels is relevant. In addition, it is useful to video record the task and record
verbal transcripts of all communications, if possible.
Once the task under analysis is complete, each ‘key’ agent (e.g. scenario com-
mander, agents performing critical tasks) involved should be subjected to a CDM
interview. This involves dividing the scenario into key incident phases and then
interviewing the actor involved in each phase using a set of pre-defined CDM probes
(e.g. O’Hare et al. 2000; see also Chapter 4 for more information on the CDM).

Step 4: Transcribe Data

Once all of the data are collected, it should be transcribed in order to make it compat-
ible with the EAST analysis phase. An event transcript should then be constructed. This
should describe the scenario over a timeline, including descriptions of activity, the actors
involved, any communications made and the technology used. In order to ensure the valid-
ity of the data, the scenario transcript should be reviewed by one of the SMEs involved.

Step 5: Construct Task Network

The first analysis step involves constructing a task network. Prior to this, the ini-
tial HTA should be reviewed and refined based on the data collected during step 3.
The Event Analysis of Systemic Teamwork (EAST) Method 7

The data transcription process allows the analyst to gain a deeper and more
­accurate understanding of the scenario under investigation. It also allows any dis-
crepancies between the initial HTA scenario description and the actual activity
observed to be resolved. Typically, activities in complex sociotechnical systems
do not run entirely according to protocol, and certain tasks may have been per-
formed during the scenario that were not described in the initial HTA description.
The analyst should compare the scenario transcript to the initial HTA and add any
changes as required.
Constructing the task network involves identifying high-level tasks and the rela-
tionships between them and creating a network to represent this. Some general rules
around the construction of EAST networks are presented in Table 1.1.

TABLE 1.1
Analysis Rules Regarding the Relationships Between Nodes Within EAST
Networks

Network Nodes Relationships Examples

Task network Represent high-level Represent instances The nodes ‘Identify legal
tasks that are required where the conduct of constraints’ and ‘Identify
during the scenario one high-level grouping site and zoning’ are
under analysis. of tasks (i.e. task linked because the
High-level tasks are network node) zoning cannot be
typically extracted from influences, is established until the site
the sub-ordinate goals undertaken in has been legally
level of the HTA combination with or is identified
dependent on another
group of tasks
Social network Represent human, Represent instances The nodes ‘Urban planner’
technological, or where agents within the and ‘community’ are
organisational agents social network interact linked as the planner
who undertake one or with one another during needs to communicate
more of the tasks the scenario under with and understand the
involved in the scenario analysis local community if an
under analysis (as informed analysis of the
identified in the HTA site is to be established
and task network)
Information Represent grouped Represent instances The nodes ‘views’ and
network categories of where information ‘topography’ are linked
information that is influences other as the establishment of
required by agents when information or is used views requires
undertaking scenario in combination with appropriate topography
under analysis (as other information in the
identified in the task and network during the
social network) scenario under analysis
8 Systems Thinking in Practice

Step 6: Conduct Social Network Analysis

A Social Network Analysis (SNA) (Driskell and Mullen 2004) is used to analyse the
relationships (e.g. communications, transactions) between the agents involved in the
scenario under analysis. This involves first creating a social network matrix show-
ing the relationships between agents followed by a social network diagram which
provides a visual representation of the social network. Typically, the direction (i.e.
from actor A to actor B) frequency, type and content of associations are recorded. It is
normally useful to conduct a series of SNAs representing different phases of the task
under analysis (using the task phases defined during the CDM part of the analysis).

Step 7: Construct Information Networks

The final step of the EAST analysis involves constructing information networks
(see Chapter 7 for a full description) for each scenario phase identified during the
CDM interviews. Following construction, information usage should be defined for
each actor involved via shading of the information elements within the propositional
networks.

Step 8: Construct Composite Networks

Composite networks are used to explore the relationships between tasks, agents
and information (Stanton 2014). As such, composite networks are constructed
by combining the different networks. For example, a task by agents network can
be constructed by combining the task and social network to show which tasks
are undertaken by which agents. This involves assigning a colour to the different
agents within the social network and shading each node within the task network
to show which agent performs that particular task. Useful composite networks to
construct include

• Task by agents network (combined task and social network);

• Information by agents network (combined information and social network);
• Task and associated information network (combined task and information
network);
• Information by agents and tasks network (combined task, social and infor-
mation network).

Once the EAST networks are complete, it is pertinent to validate the outputs using
appropriate SMEs and recordings of the scenario under analysis. Any problems iden-
tified should be corrected at this point.

Step 9: Analyse Networks

An important component of EAST analyses involved using network metrics to anal-
yse the task, social and information networks. This enables analysis of the struc-
ture of the networks and identification of key nodes (e.g. tasks, agents, information)
Discovering Diverse Content Through
Random Scribd Documents
If you had a spark of gratitude toward him, you would never have
behaved as you have done."

"How dare you speak to me in that way?"

"Because the time is past when you could play the tyrant."

"Tyrant! Tyrant! This to your mother, who bore you."

"I don't wish to be disrespectful, mother, but you are so

unreasonable that you compel me to be so. It is all very well so far
as things are between ourselves; but in this story which you have
told serious matters are concerned. Your share in them is not
honorable."

"I can do what I like," said Mrs. Beatson in a more subdued tone, for
the attitude taken up by her son impressed her unpleasantly. He was
no longer a boy to be bullied, but a man to be conciliated.

"No, you can't do what you like when your doings bring you into
trouble with the law," insisted Kit, and Sophy nodded her
approbation, which was odd considering how she dared authority as
a suffragist. But in her own way she was as unreasonable as Mrs.
Beatson, although she would never have admitted as much, and
would have been indignant at the mere suggestion.

"I won't get into trouble with the law," said Mrs. Beatson rather
nervously.

"That all depends upon what steps the police take."

"The police know nothing," said the housekeeper hastily.

"But the police will know, mother. I don't think so honorable a

gentleman as Mr. Hendle will allow things to remain as they are. He
is innocent----"
"Is he? He had every reason to kill Mr. Leigh because of the will,
which is likely to leave him a pauper."

"I say he is innocent!" shouted Kit, stamping, and the expression on

his face was such as to reduce his mother to frightened silence.
"Nothing will ever make me believe that Mr. Hendle would act in
such a wicked way."

"Then it's Mr. Mallien," whimpered Mrs. Beatson.

"No," said Sophy quickly, "Mr. Mallien knows well enough that Mr.
Hendle will act honorably about the will. He would not risk his neck
to get a document which he knew Mr. Hendle would not dispute if it
is legal."

"Well," said the housekeeper, still bent upon accusing someone, "I
shouldn't be surprised if that nasty Mr. Carrington is guilty. Mr.
Hendle went up the very next day after the conversation with Mr.
Leigh to consult him. Mr. Carrington might have killed Mr. Leigh to
get the will, so that he could make Mr. Hendle give him money for
it."

"I quite believe that Mr. Carrington did try to get money," said Kit,
after a pause, "as he had a quarrel with Mr. Hendle yesterday."

"How do you know that?"

"Someone told Mrs. Pansey that angry words passed between Mr.
Hendle and Mr. Carrington at the gate of the Park. And Mr.
Carrington slept last night at the inn before going to London this
morning."

"They did have a quarrel," admitted the housekeeper, "at least, I

suppose so, as Mr. Carrington did not stay at The Big House last
night. But we don't know if the quarrel was over money as the price
of the will. Mr. Carrington was in Town on the night Mr. Leigh was
murdered, so he can have nothing to do with it."
Sophy jumped up and clapped hands. "He was not in Town on that
night," she cried, with her eyes blazing with excitement. "Father
came down by the eight o'clock train on that night and Mr.
Carrington came also. Father saw him on the Liverpool Street station
and afterward on the Barship platform."

Kit turned on the girl sharply. "Sophy, are you certain?"

"Yes, I am. You can ask father yourself."

"But Dr. Tollart doesn't know Mr. Carrington," remarked Mrs. Beatson
anxiously.

"Yes, he does. When Mr. Carrington came down here first he called
to see father about an aching tooth. He came to this very house.
Father did not take much notice of Mr. Carrington on that night, as
he thought he was just coming down to see Mr. Hendle. He never
connected Mr. Carrington with the murder. But now, now,"--Sophy
clapped her hands again, so excited did she feel--"from what you
say, Mrs. Beatson, I shouldn't be at all surprised to hear that Mr.
Carrington was guilty."

"We can't be certain of that," said Kit quickly.

"I am certain," said Mrs. Beatson, rising, "and I'll tell Inspector
Lawson what you have told me, just to pay that Carrington out for
his poking and prying."

"I shouldn't if I were you, mother," remarked Kit dryly. "If you can
make things hot for Mr. Carrington, he can make things disagreeable
for you. Better let Mr. Hendle know first, and allow him to attend to
the matter. After all, mother," said Kit, with a shrug, "we are
assuming a great deal. Mr. Carrington may be quite innocent, and
his quarrel with Mr. Hendle may have nothing to do with the will."

"I believe he is guilty," said Mrs. Beatson viciously, and said it

because she wished to think so.
"So do I," put in Sophy, earnestly. "Still, Mrs. Beatson, I wouldn't go
to see Inspector Lawson if I were you. You might be arrested as an
accessory after the fact, you know."

"Me!" Mrs. Beatson grew white and tottered. "I have nothing to do
with--oh, Kit, Kit, do you think--do you think----"

"I think you are quite safe, so long as you hold your tongue and
allow Mr. Hendle to look into things."

"Oh, I shall not say a word!" groaned Mrs. Beatson, now thoroughly
frightened for her own skin, "and you and Sophy will keep silent for
my sake."

"I shall tell Mr. Hendle," said Kit, firmly. "I must."

"And I shall tell Dorinda," chimed in Miss Tollart. "She is engaged to

Mr. Hendle, and they can talk it over together. Union is strength, as I
know from our votes for women troubles, and if Mr. Carrington
intends to accuse Mr. Mallien, or Mr. Hendle, he will find himself in
the wrong box. They can call father as a witness if the case comes
into court."

"A new witness," declared Kit eagerly, "and one who will put the
saddle on the right horse. The mere presence of Mr. Carrington in
Barship on that night shows that he has something to do with the
matter."

"We can't be sure," murmured Mrs. Beatson weakly, for by this time
she was becoming dreadfully nervous about her share in the
proceedings.

"We'll soon make sure when Mr. Hendle questions Mr. Carrington as
to his doings in Barship on that night," said Kit decidedly. "Now go,
mother, and hold your tongue. It's dangerous to speak."
"I'll hold my tongue," promised Mrs. Beatson, and tottered away
weakly.

CHAPTER XVII

DIFFICULTIES

Kit owed a great deal to Hendle, and was never backward in

admitting that the Squire was his benefactor. When Mrs. Beatson
first took service at The Big House, the boy was at school, but she
explained to her employer that she could no longer pay fees for his
education. Rupert, approving of the bright, intelligent lad, thereupon
arranged for the rounding off of his scholastic career, and afterwards
paid for his training as an engineer. It was due to the Squire that Kit
occupied the excellent position he did in the exploitation and sale of
motors. Also it must be stated that young Beatson took every
advantage of his opportunities, earning the esteem and approval of
all with whom he came into contact. With the Squire's aid and his
own brains there was every chance that Kit would succeed in life
more than most.

Naturally the boy was deeply grateful to Hendle for his consistent
kindness; but he also adored him as an athlete, who possessed all
those out-of-door qualities which youths most admire in their
seniors. It therefore distressed him greatly when his mother came
with her tale of woe. Kit, loyal to the core, would not admit for one
instant that his benefactor was in the wrong, especially as he knew
only too well what a trying woman the Squire had to deal with. As a
parent, Kit had always found Mrs. Beatson uncomfortable, since she
invariably used her authority to force him into agreement with
herself, however unreasonable her ideas might be. Like many
another mother, Mrs. Beatson would not recognize that her son was
grown up and had a right to have his own opinions. He was to obey
her in all things and do what he was told. Kit thought otherwise,
and, as the views of the two clashed, there was always a certain
amount of friction between them. Having regard to his mother's
aggressive personality, it was extremely hard for young Beatson to
obey the fifth commandment.

Rupert knew the boy's difficulties in the adjustment of his filial duties
and greatly sympathized with him. Therefore he was by no means
surprised when Kit made his appearance at The Big House early on
Sunday afternoon. It was to be expected that Mrs. Beatson would
tell her son about her dismissal, but when Hendle heard what his
visitor had to say he was surprised to hear that the woman had been
so frank in her explanation. He made Kit sit down and repeat his
story of the interview, then walked up and down the library much
perplexed, for the boy, being the son of the woman who had been
discharged, it was by no means easy to talk to him. And Rupert was
so kind-hearted that it was a positive pain for him to say a word
against anyone. Yet what could he say in condonation of Mrs.
Beatson's extraordinary behavior? Kit saw the worried look on his
hero's face and felt worried himself in consequence. Therefore did
he try to smooth matters.

"Of course, sir, I know that my mother is rather unreasonable," he

remarked, in a low voice, twisting and turning his straw hat. "I don't
quite agree with her views, you know."

Rupert gave the boy an approving glance, as he quite understood

how unpleasant was his position. "Your mother has had much
trouble in her life, and perhaps her nature is rather warped. What
would you like me to do?"
Kit reflected, then spoke up straightly with a flush on his face. "I
think it would be better for you to allow mother to go away for a
holiday instead of dismissing her at once. While she is away, she can
give you notice and can look for another place. In this way her pride
will be saved."

"Why should her pride be saved?" asked the Squire hastily and
bluntly.

"How can I answer that question, Mr. Hendle?"

"Of course not. I beg your pardon, Kit. I should not have asked it.
What you say is very reasonable, and I have every wish to make
things easy for your mother. She shall take a holiday, and can leave
when she has found a better place."

Kit shook his young head. "She'll never find a better place, sir, or a
better friend," he said sadly. "You have been good to her, and more
than good to me. I wish mother could see things as I see them, but-
-but----"

"There! there!" Rupert clapped him on the back. "I know how you
feel and what you wish to say. Even if your mother does leave me,
Kit, that need make no difference to our friendship."

"It certainly will not," said the young fellow emphatically. "I don't
think mother has acted well; nor does Sophy."

"Your mother certainly was very explicit, Kit. I wonder she did not
make out a better case for herself."

"Well, you see, Mr. Hendle, mother never thinks that she does
wrong. It is a very difficult thing for me to say, since I am her son,
but I quite understand why you want her to go. I suggest that she
should take a holiday, and that she should give you notice on the
plea of finding another place, both to save her pride and to shut
people's mouths."
"You think they will gossip--that your mother will talk?"

"I don't think that mother will talk, Mr. Hendle: she is much too
frightened to do so, as she knows that she has not acted well. Sophy
and I told her so, and gradually she came to see that she had made
a mistake. But if you send her away people will ask the reason."

Rupert nodded and straddling on the hearth-rug put his hands

behind his back. "And I can't give any reason other than the true
one. It is impossible to give that, since it involves danger to other
people. I am glad that you persuaded your mother to hold her
tongue, Kit, and it is a great relief for me to know that you and Miss
Tollart are acting so discreetly."

"We want to help you, sir."

"I don't see how either of you can do that, Kit."

"Why not? We know the story of----"

"From your mother's point of view you know the story," interrupted
the Squire hastily, "but she does not know all."

"There is a will, which may disinherit you, I suppose, Mr. Hendle?"

"Oh, yes. The will of John Hendle, leaving everything to the elder
branch of the family, represented by Mr. Mallien. I intend to take it to
my lawyers to-morrow, after I have seen my cousin."

"Why not surrender the property to your cousin, sir, without taking
the will to the lawyers?" questioned Kit shrewdly.

Rupert shook his head. "I wish everything to be done openly."

"But seeing what is involved, Mr. Hendle, isn't there some danger of
a scandal if any public statement is made?"
"There is. All the same, if I gave up the property and sneaked away,
people would talk, and the truth might come out in a crooked way. I
wish it to come out in a straight way, and so intend to act as I say."

"Will you lose everything, sir?"

"I think so, if the will is proved to be legal. Then, Kit, I shall have to
come to ask you to get me a situation in that factory of yours."

The boy was greatly distressed. "Oh, Mr. Hendle, don't talk like that.
It is wicked to think that a kind-hearted man like you should lose
your property. I don't think Mr. Mallien will make such a good use of
the money."

"That is his affair, Kit," replied Hendle, with a sigh. "But you may be
sure that I shall do all I can do to keep the property. There is a
certain Statute of Limitations which may help me. Perhaps Mr.
Mallien and I can arrange to divide the money. But what is the use
of talking?" Rupert threw himself despondently into a chair. "You
can't help me."

"Not so far as regards the property, Mr. Hendle," said Kit earnestly;
"but I may be able to help you to clear up the mystery of the
murder."

Rupert sat up and stared. "What?"

"Oh, I don't say that I know anything for certain, sir, but I have my
suspicions, you know."

"Oh, have you? Who is it you suspect?"

"I shall tell you when you relate to me all details unknown to my
mother." Hendle rose again restlessly, and walking up and down,
thought deeply. When he paused again before Kit, he had made up
his mind to be frank. "I know you are my friend," he said earnestly,
"and I know that you are honest and true."
"I am all that," rejoined Beatson emphatically, "especially when there
is anything to be done for you, sir. I shall never forget your kindness
to me. Anything you say will go no further than Sophy."

"Why Sophy?" asked Rupert suspiciously.

"Because she knows so much that she may as well know all. And her
suspicions point in the direction that mine do. She is now with Miss
Mallien----"

Rupert uttered an ejaculation. "Not reporting the conversation with

your mother, I hope," he said hastily.

"Yes," answered Kit bluntly; "it is better for Sophy to speak to Miss
Mallien than to Mr. Mallien."

"Does she--do you--suspect my cousin?"

"No! But Sophy will explain when she brings Miss Mallien here. We
arranged to meet here shortly, Mr. Hendle"; and Kit glanced at his
watch. "I dare say the two ladies will be here in an hour."

"I didn't want Miss Mallien to know anything," said Hendle, frowning.

"It is absolutely necessary that she should know," said Beatson

calmly; "and as she loves you, sir, and is going to marry you, she
should know all. I'm always in the habit of telling Sophy my troubles,
and she gives me the best of advice. Every woman is not so
unreasonable as my mother, Mr. Hendle."

Anxious as he was, Rupert could not help smiling.

"I trust not," he said at length, and sat down quietly. "Well, Kit, you
are more shrewd than I gave you credit for being. Perhaps you can
help me, after all. Let us take advantage of the hour before the
ladies arrive to go into the matter."
"You must be quite frank with me, sir, you know."

"That is only fair. Yes. I shall be quite frank. Take a cigarette, Kit,
and listen carefully to what I have to say."

Shortly Rupert had his pipe and Kit a cigarette. The door and
windows being closed, Hendle felt quite secure, as it was unlikely
that Mrs. Beatson would indulge in eavesdropping again, seeing
what a severe lesson she had received. Hendle related slowly all that
had happened, and supplied details missing in the story of Mrs.
Beatson. He ended with a short sketch of his present position, and
the difficulty he found in deciding what action to take. Kit was so
interested in what was said that he allowed his cigarette to go out,
and when the story was ended stared tongue-tied at the Squire.
Rupert laughed at the expression on the boy's face.

"You seem as perplexed as I am," he remarked with a shrug.

"I don't think that I am perplexed," said Kit slowly and relighting his
cigarette; "only I am astonished that you have not spotted the right
man who murdered the vicar."

"Things are too muddled for me to spot anyone," replied Hendle

dryly. "My cousin accuses me; Mr. Carrington accuses your mother."

"It is ridiculous for you or my mother to be accused," said Kit quietly.

"My mother hasn't the pluck to kill a fly in spite of her tempers, and
you----"

Kit laughed. "What bosh! I'd as soon believe Sophy was guilty."

"Well, only your mother and I and my cousin knew about the will
before----"

"Mr. Carrington knew."

"Oh, yes. But he was in town on the night Leigh was killed, so----"
"He was not in town," interrupted Kit sharply. "He was in Barship."

Hendle dropped his pipe and stared. "Are you sure of what you are
saying?"

"You can ask Dr. Tollart if you doubt me."

"Dr. Tollart!" echoed Hendle, much surprised. "What does he know?"

"He came down on the evening when the vicar was murdered, and
saw Mr. Carrington both on the Liverpool Street platform and on the
Barship platform."

"Did he speak to him?"

"No. He told Sophy that Mr. Carrington had come down, but that he
had traveled in another carriage. After all," went on Beatson
thoughtfully, "there was no reason why the doctor should speak. He
had only seen Mr. Carrington once when he called on him to get a
cure for his toothache."

"Yes. I remember he went to see the doctor when he first came,"

replied Rupert mechanically. "I was in the church with Miss Mallien,
and Carrington, on his way back to The Big House, looked in about
his tooth on Tollart." He paused, then continued: "What train was
it?"

"The one which leaves Liverpool Street at eight."

"That arrives here at a quarter past nine," said Hendle meditatively.

"Yes, and as the vicar was murdered at eleven, Mr. Carrington had
plenty of time to make his plans."

"I can't believe that Carrington is the assassin," muttered Hendle, in

dismay, for he dreaded lest he should prove the accusation to be
true. "Did Dr. Tollart connect Carrington with the murder?"
"No. If he had, he would have spoken out. He took little notice of Mr.
Carrington, thinking he was coming down on a visit to you. And as
Mr. Carrington was with you the next day, of course the doctor
believed that it was as he had thought."

"Yes, I see. But Carrington did not come on that night. He came by
the midday train next day."

"The doctor didn't know that," said Kit, nodding; "in fact, he thought
no more about the matter after he told Sophy, and he only told her
as a piece of gossip, you understand."

"Yes! yes! I see that, as Carrington was with me the next day, his
presence in the eight o'clock train on the previous night would
arouse no suspicion in Tollart's mind. Still, his being at Barship on
that night doesn't mean that he killed the vicar."

"Well," said Kit, with a wisdom beyond his years, "I rather think that
it is very good evidence against him. You had told him about the
will, and he knew what it meant to you. What he said when you
kicked him out the other day shows that he wants a large sum of
money. He intended perhaps to stun the vicar and get the will, so as
to make his terms with you; but the vicar, having heart disease, died
straightway. For that reason Mr. Carrington buried the will, and sent
an anonymous letter to my mother."

"But Mr. Carrington did not know where the sundial was. How, then,
could he find it in the nighttime, hidden as it was among the
bushes?"

"Oh, I can't explain everything," said Beatson frankly; "but you must
admit, sir, that it is odd Mr. Carrington should have been in Barship
on the night of the murder, without saying a word to you. If his
intentions had been innocent, he would have come for the night to
you."

"True enough, Kit. I wonder where he did spend the night?"

Kit shrugged his shoulders. "You will have to ask him that. I really
believe that he is the guilty person."

"But what about that opal in the matrix which belongs to my cousin?
It was found by me on the verge of the hole where the will was
buried."

"Did you find it?"

"Well, no. It was Carrington who pointed it out glittering among the
grasses. I merely picked it up."

"Well," said Kit, with a judicial air, "the person who loses generally
manages to find. How do you know that Mr. Carrington didn't drop
the opal there when your back was turned?"

"You are very rapidly weaving a rope for the man's neck," observed
Hendle dryly. "After all, we are taking a great deal for granted."

"Well, sir, all you have to do is to ask Mr. Carrington to explain."

"Humph! That will be awkward, considering we are declared

enemies. However, we shall see. I think it will be best to speak to
my cousin first."

Kit agreed with this suggestion and then held his tongue. He had
said all that he could say, and having placed the Squire on his guard,
there was nothing more to be done. Rupert himself did not pursue
the conversation further, but walked up and down, musing over what
he had heard. For quite five minutes there was silence, and then
Dorinda made her appearance, followed by Miss Tollart. The girl
looked very pale and anxious.

"What does all this mean, Rupert?" she asked nervously.

"All what?"
"Sophy has told me a strange story," said Dorinda, taking a seat,
"and I suppose Kit has told it to you also."

Hendle nodded. "Yes. I know that Carrington was in Barship on the

night when Leigh was murdered--unless, of course, Dr. Tollart has
made a mistake."

"My father made no mistake," struck in Sophy, flushing, for she

guessed that the Squire was hinting at the doctor's infirmity. "He
was quite sober when he came home on that night. I was waiting up
for him. He mentioned in quite a casual way that Mr. Carrington had
traveled down by the same train, and neither of us thought anything
more about the matter, even when we heard next morning about the
murder. We thought that Mr. Carrington had come down to see you,
Squire, and he certainly was with you the next day."

"He was," admitted Rupert quietly, "and his being with me made you
believe that what you thought was true. Is it not so?"

"In a way. But the real truth is that neither my father nor myself
thought anything at all about the matter. Only Mrs. Beatson's hint
that Mr. Carrington might possibly be guilty made me remember."

"Do you think that the man is guilty?" asked Rupert quickly.

Sophy bent her dark brows in a frown and reflected. "I couldn't go
into a witness box and swear that he committed the murder," she
observed; "but he came down to Barship on that night, and if he did
not stay with you, Mr. Hendle, he must have had some strong reason
to keep his visit a secret."

"Your father can swear to this visit?"

"Yes. I asked him again if he remembered Mr. Carrington coming

down, and he said that he could. Of course," added Sophy
significantly, "I had to ask the question in a way not likely to arouse
my father's suspicions as to why it was asked. It is no use letting
him know too much, as he might talk. But if necessary he can prove
what he told me."

Dorinda shivered. "I never liked Mr. Carrington," she observed. "All
the same, I can't believe that he murdered Mr. Leigh."

"Some one must have murdered him," said Kit, a trifle dryly; "and
why not Mr. Carrington, rather than your father, or the Squire? For
my part, going by what Mr. Hendle has told me, I believe Mr.
Carrington is guilty."

"How are we going to prove him to be guilty?"

"Well," said Rupert doubtfully, "I see no way save asking him to
explain why he came down to Barship on that night. Unless he gives
a reasonable excuse, he will be in danger of being arrested."

"But, Rupert, in that case my father will be in danger."

"How so?"

"Don't you know that Mr. Carrington sent for my father the other
day, and had an interview with him at The Hendle Arms?"

"No. What did he wish to see your father about?"

"He threatened to accuse him of committing the crime, so as to gain

possession of the will. I don't know exactly what passed," went on
Dorinda anxiously, "as my father told me little. All he really said was
that he was in danger of being arrested, because Mr. Carrington
could give evidence against him, which would be difficult to
disprove."

"But your father surely did not admit that he was guilty, Dorinda?"

"Certainly not," cried the girl, flushing indignantly. "How can you
suggest such a thing? But as Mr. Carrington wants money he is
ready to say anything or do anything likely to force my father into
paying him to hold his tongue."

Rupert smiled grimly. "Carrington knows that your father has not
sufficient money to pay him what he wants."

"What does he want?" asked Sophy, looking up.

"Five thousand pounds was the price he demanded from me," said
Hendle, "and I don't think he'll take a penny less from Mr. Mallien.
But in order to get the money Carrington will have to wait until my
cousin is in possession of my property. Until then you can be sure,
Dorinda, that he will take no steps to make things uncomfortable."

"No, I think you are right," murmured Miss Mallien, greatly relieved.
"But what is best to be done?"

"I have already made up my mind. In the first place I shall see your
father and learn exactly what took place at this interview. Afterwards
we can have a talk with Carrington. Then he will----"

"Oh, let the will alone until we learn the truth about this murder,"
urged Dorinda anxiously. "To clear my father from all chance of
being accused is the first thing to be done. See my father, Rupert;
perhaps he will be more frank with you than he was with me."

"He must be frank if he wants to save himself," said Sophy bluntly.

"Don't worry, Dorinda. My opinion is that we should give Mr.
Carrington plenty of rope with which to hang himself. When he is
fully committed, then we can turn the tables on him by saying what
we know of his presence in Barship on the night of the murder.
There's nothing to be afraid of."

"I'm not exactly afraid," said Dorinda slowly, "but the suspense is
very trying, with Mr. Carrington working in the dark."
"We'll force him to come out into the open, Miss Mallien," said Kit
resolutely; "then he will have to defend himself, and won't have time
to accuse other people. He shan't have everything his own way,
anyhow."

"Hear! hear!" cried Sophy, clapping her hands. "You're a brick, Kit.
For my part I believe that Mr. Carrington has only to be faced boldly
to bring him to his knees."

Rupert shook his head. "He can do some damage before he is forced
to take up that position."

"What does it matter, so long as the damage won't be lasting?" said

Dorinda impatiently. "I am certain that my father is innocent."

"And so am I," finished Hendle with a shrug; "so there only remains
Carrington as the possible criminal. Well, we shall see. Anyhow, as
he won't move until my cousin is in possession of the property, we
have ample time to arrange what is best to be done. Meantime let
us keep what we know to ourselves."

"But what about Mrs. Beatson?" hesitated Sophy, glancing at Kit.

"Mrs. Beatson," said Rupert, grimly polite, "is going away for a
holiday, and if she hears of a better situation she will not return
here."

"I'm glad of that, Squire!" and Sophy, guessing the plan which was
to save the housekeeper's pride, felt greatly relieved. Little as she
liked her future mother-in-law, she did not wish to see her
disgraced. "And now I think Kit had better take me home."

"But I have more to say," began Kit anxiously, only to be silenced by

Sophy.

"No, you haven't," she declared imperiously, and marched him to the
door. "You have given the Squire quite enough to think about"; then
she sank her voice to scold: "Don't be a fool. They want to be
alone!"

"Oh!" murmured Kit, "I see"; and he submitted to be led away.

CHAPTER XVIII

SETTING A TRAP

Mallien, by telling his daughter a half truth instead of the whole

truth, had made her very nervous, and although she asked for a
more detailed explanation he had refused to give it to her. Dorinda
was therefore much relieved when Sophy conducted her to The Big
House and hidden matters were made more plain. When in
possession of facts she quickly recognized that the position of her
father was highly dangerous, should Carrington speak to the police.
But the girl agreed with Rupert that he would not do so, until all
chance of getting money for his silence had disappeared. Even if
Mallien was willing, such money could not be obtained until the
property passed from the Squire to his cousin, so if Rupert refused
to give up the same, Carrington would be forced to wait. It was not
likely that he would kill the goose with the golden eggs by speaking
prematurely.

And there was, as Rupert pointed out to Dorinda, a grave doubt

whether he would speak at all, when informed that his presence in
Barship on the night of the murder was known. Hendle intended to
question the barrister on this point and hear what defense he could
offer, but before doing so, desired to see his cousin and enlist his
aid. It was even more to Mallien's interest than to Rupert's to bring
Carrington to book, and only by the cousins joining forces could they
accomplish their end. And that was, to learn for certain who had
murdered the vicar. It assuredly seemed as though the barrister was
the guilty person, and should the crime be brought home to him, his
evil scheme to acquire money by blackmail would be frustrated.
Instead of accusing Mallien to the police, it was probable that
Carrington would be forced to fly lest Lawson should lay hands on
him. Dorinda returned home in a much more comfortable frame of
mind, since Rupert thus placed matters in a better light. She was
also more content because affairs were in her lover's hands. He, if
anyone, would be able to make the crooked straight.

One of Hendle's last injunctions to the girl was that she should say
nothing to her father about her visit to The Big House. He warned
her not to repeat what she had heard, and not to question her father
in any way regarding his dealings with Carrington. Rupert arranged
matters thus because he intended to call on his cousin next day and
have a complete understanding with him. Mallien therefore was
much annoyed, and very illogically so, when his daughter no longer
implored him to be plain with her. On Sunday evening and Monday
morning she saw him looking gloomy and disturbed, yet made no
effort to cheer him, or, as he put it, to bear his burden. Dorinda
laughed outright when her father made this last remark.

"Really, father, you are unreasonable," she observed, when putting

on her hat to go shopping in the village. "How can I bear your
burden when you won't tell me what it is?"

"I have told you," growled the little man crossly, "that blackguard
Carrington dares to accuse me of murdering Leigh."

"Well," said Dorinda lightly, "as you didn't murder him what does it
matter?"
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