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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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Boca Raton, FL 33487-2742

© 2019 by Taylor & Francis Group, LLC

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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
LC record available at https://lccn.loc.gov/2018026593

Visit the Taylor & Francis Web site at

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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
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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
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discover a wide range of
eBooks across various genres.
Enjoy exclusive deals and
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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)
Exploring the Variety of Random
Documents with Different Content
 We have also heard the noise at the top of the Rue Basse Cour,
which was made by the arrival of the forty hussars of M. Goguelot
and M. de Choiseul, in the midst of whom I recognised M. de Malmy,
who had, without doubt, served as their guide.
We can, therefore—a light being thrown on the past,—resume the
thread of our story, without fear of complication or confusion.
 CHAPTER XXX.
W H AT H A P P E N E D I N T H E G R O C E R ’ S L I T T L E S H O P.

At the end of some minutes, during which they had been

parleying, M. Goguelot and M. de Choiseul contrived to get admitted
to the King.
M. Sauce, who, after he had conducted his guests to the chamber
in which they were confined, had descended to get the key,
remounted the stairs, followed by M. Goguelot and M. de Choiseul.
On seeing M. Goguelot, the King joyously clapped his hands, for
he was the only person that he knew whom he had as yet seen. He
was, without doubt, the precursor of assistance.
Behind M. Goguelot, he recognised M. de Choiseul.
Other footsteps were heard on the staircase—they were those of
M. de Damas.
The three officers, as soon as they entered, bent looks of inquiry
around them.
This is what they saw on entering, and what I saw from my
window.
A narrow room, in the midst of which was a cask, which served as
a table; on that table was placed some paper and some glasses. In a
corner stood the King and Queen; by the window were Madame
Elizabeth and Madame Royale; in the background, the Dauphin,
overcome with fatigue, was sleeping on a bed, at the foot of which
was Madame de Tourzel; at the door were stationed the two
femmes-de-chambre—Madame de Neuville and Madame de Brunier,
acting as sentinels—or, rather, two women armed with forks.
 The first word that the King uttered was, “Well, gentlemen, when
do we start?”
“When it pleases your Majesty.”
“Give your commands, sire,” said M. de Choiseul. “I have with me
forty hussars; but lose no time. We must act before the citizens have
an opportunity of bribing my men.”
“Well, gentlemen, descend, and clear the way; but mind, no
violence.”
The young men went down.
The moment that M. de Goguelot had his hand on the street door,
the National Guard summoned the hussars to dismount.
“Hussars,” cried M. de Goguelot, “remain in your saddles.”
“Wherefore?” queried the officer commanding the National Guard.
“To protect the King,” replied M. de Goguelot.
“Good!” returned the officers; “we can take care of him without
you.”
A hundred voices at the same time cried, “Yes, yes, yes! Make the
hussars dismount! It is our business, and not the business of
strangers, to protect the King! Dismount, hussars—dismount!”
M. de Damas slipped through the crowd, and rejoined the three or
four men who had been faithful to him.
M. de Goguelot exchanged signals with M. de Malmy, and in
company with M. de Choiseul again ascended to the King’s chamber.
Both addressed the Queen, as they knew that it was her head that
planned.
“Madame,” said M. de Goguelot, “it is no use thinking of
proceeding in the carriages; but there is a way of safety.”
“What?”
 “Will you mount a horse, and set out with the King? He will take
charge of the Dauphin. The bridge is barricaded, but at the bottom
of the Rue Jean the river is fordable. With our forty hussars we will
pass. In any case, make a quick resolution. Our hussars are already
drinking with the people; in another quarter of an hour they will be
brothers.”
The Queen drew back; that iron heart failed her at that critical
moment. She again became a woman; she feared a struggle, a
skirmish—perhaps a bullet.
“Speak to the King, messieurs,” said she; “it is he who should
decide on this plan; it is he who should command; it is for me but to
follow.”
She then added, timidly, “After all, it cannot be long before M. de
Bouillé arrives.”
The gardes du corps were there ready to attempt anything.
M. de Valory said, in his and the name of all his comrades, “Her
Majesty knows that she can command. We are ready to die for her.”
M. de Goguelot and M. de Choiseul chimed in.
“M. de Damas is below,” said M. de Choiseul; “he told us to tell
your Majesty that he had but three or four dragoons, but that he
could count on their fidelity as on his own.”
“Let us set out, sire—let us set out, since the Queen places herself
in your hands.”
If the King replied yes, there was still hope.
“Messieurs,” asked the King, “can you promise me that in the
struggle which must take place as a consequence of our departure,
no ball will strike the Queen, my sister, or my children?”
A sigh passed the lips of the King’s defenders. They felt him giving
way in their hands.
 “Let us reason coolly,” said the King. “The municipal council do not
refuse to let me go. The annoyance is, that we are compelled to
spend the night here; but before daybreak, M. de Bouillé will be
acquainted with the situation in which we are. He is at Stenay.
Stenay is but eight leagues from here; two hours will take one there,
and another two suffice to bring back a message. M. de Bouillé
cannot fail to be here in the morning, then shall we depart without
danger or violence.”
As he uttered these words, without announcing themselves, or
asking the permission of the King to be admitted, the municipal
council entered the room.
The decision that they had arrived at was brief and precise.
The people strongly objected to the King’s continuing his route,
and had resolved to send a courier to the National Assembly to know
its sentiments.
In fact, a citizen of Varennes, an M. Maugin, surgeon by
profession, had started at full speed for Paris.
M. de Goguelot saw that there was not an instant to lose; he
dashed from the house, and found M. de Malmy at the door.
“Monsieur,” he said, “you live here, therefore you know this part of
the country. A man, come what will, must set out for Stenay to
advise M. de Bouillé of the predicament in which the King is placed,
and return with a sufficient force to rescue him.”
“I will go myself,” said M. de Malmy.
And sticking his spurs into his horse, he set off at a gallop.
At M. Gerbaut’s door, he saw a file of National Guards, who
commanded him to stop.
“All very well,” replied M. de Malmy; “but I intend to go on.”
“Not you, more than another!” cried an officer, seizing his horse by
the bridle.
 “If you advance another step,” said M. Roland, the commander of
the National Guard, cocking a pistol, “I will shoot you.”
M. de Malmy, without reply, spurred his horse right on to him.
M. Roland fired off the pistol so close that the flame blinded M. de
Malmy’s horse, at the same time as the bullet passed through the
fleshy part of the horseman’s arm.
The frightened animal reared, and fell back upon his master.
From the chamber where I was engaged in watching the King, I
heard the pistol-shot, the fall of the horse and man, and the scream
of a woman.
I recognised the voice of Mdlle. Sophie. I dashed down stairs, and
arrived in time to see her throw herself on the breathless, and, as
she thought, dead body of M. de Malmy.
“Réné, Réné!” she cried. “Help me—oh, help me!”
I rushed out of the house, took M. de Malmy in my arms, and, at
the moment when he tried to stand, I took him into the house, and
laid him on M. Gerhaut’s bed.
“He is dead—he is dead! They have killed him, the wretches!”
cried the unhappy and despairing girl, who was covered with the
blood which had flowed from his wound.
At this moment, M. de Malmy opened his eyes.
“He is not dead, Mdlle. Sophie,” cried I.
“Oh!” said she.
And she threw herself prostrate on the bed.
“Leave me—leave me!” said M. de Malmy, making an effort to lift
himself up. “I must go and seek M. de Bouillé.”
Pain and weakness compelled him to fall back again.
“In the name of heaven, stay there, Alphonse!” cried Mdlle.
Sophie. “Do not move, or you will uselessly throw away your life.
You owe me somewhat; grant me that favor.”
“I must,” said the young man. “I think that my leg is broken.”
“Réné, Réné! I pray, I implore you, my friend—my brother—run
for a surgeon!”
“Immediately!” said I, dashing out into the street.
But it was impossible to move.
The crowd had become something fearful.
“Hussars!” cried M. de Goguelot, “are you for the King or the
nation?”
They all replied, “For the nation!”
“The others?”
“For the King—for the King!” they cried out, in German.
“Do you hear them?” said M. Drouet. “They are strangers—they
are Germans—that is to say, enemies.”
“No, sir,” cried the officer; “it is a Frenchman, who, in good
French, says to you, ‘Make way, in the name of the King!’”
“And I reply to you, in better French, if your hussars do not lay
down their arms, we will fire on them, and not one shall leave
Varennes alive. Soldiers, present arms—and, gunners, to your
pieces!”
Then, stepping two paces forward, he said to M. Goguelot, “Take
care, sir. I have sighted you with my gun.”
“Vive la nation!” cried the hussars, as they saw the musket barrels
pointed at them, with the matches burning brightly in the obscurity,
and the two little pieces of cannon placed in battery at the bottom of
the Rue St. Jean.
At this moment, several National Guards sprang upon M.
Goguelot’s horse, snatched the rider from the saddle, and dashed
him head-foremost into the road, where he lay for a moment or so,
completely stunned.
They treated M. Damas and M. de Choiseul, who appeared on the
door-step at that moment, in the same fashion.
In the midst of this struggle, I set out for the Place Latry, by way
of the Rue l’Horloge. When I got there, I found that M. Maugin had
started for Paris, by wish of the municipality, at full speed.
I ran to the house of another doctor of less skill than M. Maugin—
a M. Saulnier—and brought him to the Rue de la Basse Cour, where
the hussars were drinking and fraternizing with the National Guard.
M. de Malmy was wounded in the shoulder by a ball which had
traversed the deltoid muscles. His leg was not broken, but his knee
was badly sprained.
Mdlle. Gerbaut, who feared that the condition of the wounded
man would not be improved by his remaining on the ground floor in
direct communication with the street, begged us to carry M. de
Malmy into a chamber where the surgeon could pay, without
inconvenience, all the cares necessary to a man in his condition.
I assisted M. Saulnier—a sufficiently difficult job—to carry a man
who could use neither his left arm nor his right leg. Afterwards, as I
saw that my presence was not welcome to Mdlle. Sophie, and as I
felt no particular interest in the wounded man, I retired, so as not to
lose a single scene of the drama which was being played out before
my eyes, and which was nothing less than a duel between a King
and a nation.
 CHAPTER XXXI.
T H E R E T U R N O F R O Y A LT Y I N A R R E S T.

In the midst of the tumult which was produced by the disarming

of M. de Choiseul and M. de Damas, and the cries of “Vive la
nation!” shouted out by the hussars, to the great delight of the
people, M. de Goguelot, profiting by a moment of inattention on the
part of his guards, rushed up-stairs, and, all bleeding as he was,
entered the chamber of the King.
His head had been cut open by the fall, but he did not feel the
wound.
The appearance of the chamber had changed. It had become a
prison.
Marie Antoinette, who was in reality the strength and life of the
family, was overwhelmed. She had heard the cries, the shots, and
she saw M. de Goguelot return all covered with blood.
The King, standing upright, prayed M. Sauce, the grocer, to assist
them; as if he had the power, even had he wished to do so.
The Queen, seated on a stool between two packages of candles,
likewise implored his assistance.
But with brutal and petty selfishness, he replied, “I should like to
be able to serve you, certainly; but if you think of the King, I think of
M. Sauce.”
The Queen turned aside, shedding tears of rage.
She had never been so humbled before.
The day began to dawn.
 The crowd filled the street, the Place de la Rue Neuve, and the
Place Latry.
All the citizens cried from their windows, “To Paris—to Paris—to
Paris with the King!”
Alas! to show himself—he was to appear no longer, as on the 6th
of October, on the balcony of the marble court, but at the windows
of a grocer’s house.
The King had fallen into a state of torpor.
The cries redoubled.
Five or six people had seen, or rather had caught a glimpse, of the
King; the others wished to inspect him thoroughly.
At that period, when it took a diligence six or seven days to go to
Paris, to have seen the King was a thing to talk about. Each one had
formed an imaginary portrait of him for him or herself.
Therefore the astonishment was intense when Louis the Sixteenth
showed himself with swollen eyes, and proved to that multitude a
thing which they did not before believe—namely, that a king may be
fat, pale, bloated—with dull eyes, hanging lips, a bad peruke, and a
gray suit of clothes.
The crowd believed that they were being deceived, and growled
accordingly.
Afterwards, when they knew that it was the King, “Oh, heavens!”
said they. “Poor man!”
Pity having once seized them, their hearts opened, and they
began to shed tears.
“Long live the King!” cried the crowd.
If Louis XVI had profited by that moment—if he had prayed that
concourse of people to help him and his children,—perhaps they
would have passed him and the royal family over the barricaded
bridge, and delivered them into the hands of the hussars.
 He took no advantage of that pity and sorrow.
An example was given of the commiseration which the royal family
inspired.
Sauce had an aged mother—a woman of some eighty years of
age. She was born in the reign of Louis XIV, and was a Royalist. She
entered the chamber; and seeing the King and Queen bowed down
with sorrow, and the children sleeping on the bed, which had never
been destined for such a mournful honor, she fell on her knees
beside it, repeated a prayer, and, turning towards the Queen,
“Madame,” said she, “will you allow me to kiss the hands of the two
innocents?”
The Queen bowed her head, in token of assent.
The good woman kissed their hands, and left the room, sobbing,
as if her heart would break.
The Queen was the only one who did not sleep.
The King, who had need, whatever his preoccupation of mind
might be, to eat and sleep well, having neither ate nor slept to his
satisfaction, was distracted.
About half-past six, M. Deslon was announced.
M. Deslon had arrived from Dun with about a hundred men.
He had found the Rue de l’Hôpital barricaded; had held a parley;
and demanding admission to the presence of the King, was accorded
permission to visit him.
He informed them how, at the sound of the tocsin, he had hurried
on; and that M. de Bouillé, warned by his son and M. de Raigecourt,
would, without doubt, arrive in a short time.
The King, however, seemed as if he did not hear him.
Three times M. Deslon repeated the same thing, and rather
impatiently the last time.
“Sire,” said he, “do you not hear me?”
 “What do you wish, monsieur?” said the King, as if starting from a
reverie.
“I ask your commands for M. de Bouillé, sire!”
“I have no more commands to give, monsieur—I am a prisoner.”
“But, at least, sir—”
“That he does what he can for me.”
M. Deslon retired, without being able to obtain another answer.
In fact, the King was indeed a prisoner.
The tocsin had completed its dismal task. Every village had sent
its contingent. Four or five thousand men encumbered the streets of
Varennes.
About seven in the morning, two men arriving by the Clermont
road, and bestriding horses flecked with foam, pushed their way
through the multitude.
The shouts of the people announced something new to the King.
Soon the door opened, and admitted an officer of the National
Guard.
It was the same Rayon, who, whilst snatching a moment’s rest at
Châlons, sent on an express to St. Menehould.
He entered the royal chamber fatigued, excited, almost mad,
without a cravat, and with his hair unpowdered.
“Ah, sire,” said he, in a hoarse voice—“our wives, our children!
They slaughter them at Paris, sire; you will not go much further. The
interest of the State—”
And he fell, almost fainting, into an arm-chair.
“Well, sir,” said the Queen, taking his hand, and showing him the
Dauphin and Madame Royale sleeping on the bed, “am I not a
mother, too?”
“In short, sir,” said the King, “what have you to announce to me?”
 “Sire, a decree of the Assembly.”
“Where is it?”
“My comrade has it.”
“Your comrade?”
The officer made a sign to open the door.
One of the gardes du corps opened it, and they saw M. de Romeuf
leaning against the window of the ante-chamber, and weeping.
He came forward, with downcast eyes.
The Queen started at sight of him.
It was the same young man who had accompanied M. Lafayette in
the visit he had paid the King just a quarter of an hour before he
started.
“Ah, monsieur! is it you?” said the Queen. “I could never have
believed it.”
It was she who should have blushed before him, and she tried to
make him blush.
M. de Romeuf held in his hands the decree of the Assembly.
The King snatched it from him, cast his eyes over it, and cried,
“There is no longer a King in France!”
The Queen took it in her turn, read it, and returned it to the King.
The King re-read it, and then placed it on the bed where his
children slept.
“No—no!” cried the Queen, exasperated, furious, mad with hate
and anger; “I do not wish that infamous paper to defile my children.”
“Madame,” at last said Romeuf, “you have just reproached me for
being charged with this mission. Is it not better that I should have
undertaken the task than one who would have borne witness with
regard to transports of passion?”
 There was, in fact, at this action of the Queen’s, a terrible murmur
among the spectators.
The Queen had crumpled up the decree, and dashed it on the
floor.
M. de Choiseul, who had regained his liberty, and who, at the
moment, entered the chamber, accompanied by two messengers,
picked up the decree, and placed it on the table.
The Queen appreciated his intention, and thanked him with a look.
“At least, sir,” said she, addressing M. de Romeuf, “I hope that you
will do all you can for M. de Choiseul, M. de Damas, and M. de
Goguelot when we are gone.”
In fact, the Queen well understood that go she must.
It was seven o’clock in the morning, and M. de Bouillé had not put
in an appearance.
The peasants of the villages round Varennes continued to pour
into the town, armed with guns, pitchforks, and scythes, and each
cried louder than the other, “To Paris! to Paris!”
The carriage was in readiness.
The King made the most of each little obstacle, counting each
moment, awaiting Bouillé.
At last, it was necessary to make a move.
The King rose first.
The Queen followed his example.
One of her women—whether naturally, or whether as an artifice,
to gain time—fainted.
“They may cut me into pieces if they will,” said the Queen, “but I
will not leave without one who has the misfortune to be my friend.”
“As you will—stay if you like,” said a man of the people, “At any
rate, I will take the Dauphin.”
 He took the royal child in his arms, and stepped towards the door.
The Queen seized the Dauphin from him, and descended the
stairs, blushing.
All the family were filled with poignant anxiety. On arriving in the
street, Madame Elizabeth perceived that half of the Queen’s hair had
turned gray; the other half was to grow gray at the Conciergerie in a
second night of agony, which was not, perhaps, more terrible than
that which we have recounted.
They got into the carriage; the three gardes du corps mounted on
the box.
M. de Goguelot, in the hope of bringing succor, had found means
of escaping through the little passage situate at the back of the
house of M. Sauce.
M. de Choiseul and M. de Damas were conducted to the city
prison, where M. de Romeuf caused himself to be imprisoned with
them, for the sake of protecting them more efficiently.
At last, after having exhausted every possible means of delay, the
carriage started, escorted by the National Guard, under the
command of M. Signemont, by the hussars of M. de Choiseul, which
had been sent to protect his flight, and by more than four thousand
citizens of Varennes and its suburbs, armed with guns, pitchforks,
and scythes.
The carriage of the King did not, as some historians say, pass the
house of the grocer, Sauce; that was the historical limit of the fatal
journey.
The moment that the carriage moved, I felt great doubt—or,
rather, great remorse.
The catastrophe of the arrest of the King had brought in its train
an event which, though I have but mentioned it in the place it
occupied relatively to that arrest, influenced in a strange manner the
whole of my life.
 One can readily understand that I speak of M. de Malmy’s wound;
of the impression that that wound produced on Mdlle. Sophie, and of
the involuntary avowal that, on her part, she had made to me.
I had a deep affection for Sophie. This affection, more than
fraternal, had a spice of jealousy in it; although I must do the poor
girl the justice to say that from the moment that she perceived my
nascent love, she had done all she could to nip it in the bud, by
telling me that she could never be anything more than a sister to
me. I always had the suspicion—I will not say that my rival, for there
was no real rivalry, was M. de Malmy.
This time I could no longer doubt it, and I felt it impossible to
remain under the same roof with him. Not only because Sophie
loved him and he loved Sophie, but because I knew that he was the
origin of all the misery and unhappiness that was gradually wearing
her away.
As soon as I saw the King ready to set out, and the carriage about
to move on to Paris, I bade adieu to M. Gerbaut, without telling him
that I did not think of returning to Varennes, and started off without
having the courage to see Sophie, whom however, I unexpectedly
found in my road, barring up the corridor.
“What, Mdlle. Sophie!”
She threw herself, weeping, on to my neck.
“Each one has his destiny, my good Réné,” said she. “Mine is to
suffer. I shall accomplish it.”
“Shall I always be your brother?” asked I, weeping myself.
“Ah, yes! And if ever I have need of you, I will show you that I am
your sister, by coming to you for assistance.”
“Heaven guard you, Mdlle. Sophie,” cried I, withdrawing myself
from her embrace.
“And you, also—heaven bless you, Réné!”
 And I heard the sobs which followed these words even as far as
the door which opened into the street.
I took my place at the door of the King’s carriage, making a signal
to MM. Drouet and Guillaume, who were on horseback, with the
intention of preceding the carriages, in order to make way for, and
protect them.
What was M. de Bouillé doing at this time? We will tell you in the
following chapter.
 CHAPTER XXXII.
W H AT M . D E B O U I L L E D I D I N T H E M E A N T I M E .

M. de Bouillé was at Dun, where he had passed the night in a

state of mortal disquietude.
It was the advanced post of his watch.
At three o’clock, having received no news, he proceeded to
Stenay.
At Stenay he was in the centre of his forces, and was able to act
with greater facility, having at his disposal a great number of men.
From four to five o’clock he was successively joined by M. de
Rohrig, M. de Raigecourt, and by his son.
He then knew all.
But M. de Bouillé could but little depend on his men. He was
surrounded by hostile villagers, as he called them—that is to say,
patriotic. He was menaced by Metz, by Verdun, and by Stenay. It
was his fear of Stenay that had caused him to quit Dun.
The Royal German was the sole regiment on which he could
depend. It was necessary to keep up their loyalty.
M. de Bouillé and his son Louis sat themselves to the work body
and soul.
A bottle of wine and a louis per man settled the affair.
But it took two hours to arm and set out.
At last, he started; but at seven o’clock, just at the time when the
King got into the carriage.
 In two hours he covered the eight leagues which separated him
from Varennes.
On the road he met a hussar.
“Well?”
“The King is arrested.”
“We know it. What then?”
“He has just set out from Varennes.”
“Where goes he?”
“To Paris.”
Bouillé did not give himself time to reply.
He dashed his spurs into the flanks of his horse.
His regiment followed him.
Varennes saw the regiment descend “like a waterspout amongst
its vines,” to quote the language of the proces verbal.
When he arrived at the Place du Grand Monarque, the King had
started more than an hour.
He acted so as to lose no time. The Rue de l’Hôpital was
barricaded; the bridge was barricaded. They made a detour round
the town; they crossed the river by the ford at the Boucheries, in
order to take up a favorable position on the Clermont road, to attack
the escort.
The order was given, and the manœuvre accomplished.
The river was crossed.
A hundred steps more, and they would be on the road.
But the Moulin Canal was on their way—six feet deep, and
impossible to ford.
It was necessary to stop and march back.
 For an instant, they held the idea of fording the river at St.
Gengoulf, taking the Rue St. Jean, passing through Varennes and
falling on the rear of the escort.
But the dragoons were fatigued; the horses rebelled at every step.
It would be necessary to fight a way through Varennes, and to fight
to get to the King.
They said that the garrison of Verdun were on the march, with
some cannon.
Their courage failed them. They felt that all was lost.
M. de Bouillé, weeping with rage, dashed his sword into its
sheath, and ordered a retreat.
The inhabitants of the high town saw him and his men standing
there for an hour, unable to make up their minds to return.
Eventually he and his men took the route to Dun, and disappeared
in the distance.
The King continued his way—the way of the Cross.

After the arrest of M. Dandoins and his lieutenant, an officer of

the National Guard, Citizen Legay, had established under the trees at
the angle of the Rue de la Post au Bois and the Rue du Marais a post
of National Guards, picked men, and all ordered to fire on any one
entering or leaving the city at a gallop, without responding to the
challenge of the sentinels.
Some minutes after these orders had been given, a report was
circulated that the hussars of Pont-de-Somme-Vesles had gone
round the town, and that Drouet and Guillaume ran a great risk of
falling into their hands.
M. Legay then asked for two volunteers to go with him on the
road, and pick up what information they could with regard to Drouet
and Guillaume.
 Two gendarmes, Collet and Pointe, offered themselves, and all
three set out on their voyage of discovery.
On the road they met the two citizens of St. Menehould, who had
started on sorry hacks, and been unable to keep up the chase. They
learnt from them that no accident had happened to the two
messengers. Anxious to be the bearers of this good news, they put
their horses to the gallop, and, forgetting the orders given by Legay,
omitted to answer the challenge of the sentinels in ambuscade.
The sentinels fired. Two of the horsemen fell; one dead, and the
other wounded.
Legay received five or six shots in the arm and hand.
The same day that the King repassed St. Menehould, the slain
gendarme was buried.
The King, on arriving, found the church hung with black, and the
whole town prepared to follow the body to its last home.
 CHAPTER XXXIII.
A N O L D A C Q U A I N TA N C E T U R N S U P.

Nothing important passed between Varennes and St. Menehould.

The illustrious prisoners, starting at every new noise, lost in a
measure, as they approached the latter town, every hope of succor.
The first thing they encountered was a sort of rebuke from the
dead. Of course, I allude to the interment of the man shot in the
evening by the sentinels.
The royal carriages stopped in order to allow the funeral
procession to pass. Two kings found themselves face to face with
each other—a living majesty and the King of Death. The living King
recognised the power of King Death, and bowed down before him.
St. Menehould was crowded. The National Guard poured in from
all points, those from Châlons coming in public or private vehicles. In
fact, the affluence of people was such that they feared a lack of
provisions.
In the midst of all these people coming and going, I recognised,
mounted on a little pony, M. Dampierre, our old chasseur of the
Forest of Argonne. He knew me, and came to me, trying to force the
line of guards on duty at the side of the gates.
It was I who repulsed him, because he did not count on my
resistance.
“Pardon, M. le Comte,” said I; “you cannot pass!”
“Why can I not pass?” asked he.
“Because it is ordered that none shall be allowed to approach the
King’s carriage.”
 “Who gave that order?”
“Our Captain, M. Drouet.”
“A revolutionist!”
“Possibly so, M. le Comte; but he is our commander, and we are
bound to obey him.”
“Is it forbidden to cry ‘Vive le Roi?’”
“No, M. le Comte; we are all Royalists.”
M. de Dampierre lifted his hat as high as his length of arm would
permit him, raised himself in his stirrups, and cried “Vive le Roi!”
The King put his head out of the window, and without any
expression of gratitude or remembrance, bowed to him.
M. de Dampierre retreated out of the crowd with trouble, being
obliged to make his horse go backwards. I remember him as well as
if the events occurred but yesterday. He wore gray trousers, long
riding boots, a white waistcoat, a three-cornered hat, trimmed with
gold lace. As usual with him, he carried, slung over his shoulder, a
little single-barrelled gun.
I lost sight of him. I fancied that he took the direction of the Rue
de l’Abreuvoir.
During this time, the Mayor and members of the municipality had
advanced as far as the bridge of the Aisne, situate at the extremity
of the Porte au Bois, to meet the royal family.
A municipal officer then took occasion to speak, and to tell the
King what alarms his flight had caused in France.
Louis XVI was contented to reply, with an ill-tempered air, “I never
intended to leave my kingdom.”
The crowd was so great that we took half an hour to go five
hundred yards.
About half-past eleven, the King mounted the steps of the Hotel
de Ville, his garments covered with dust, and his face altered and
careworn.
The Queen dressed in black. She had changed her robe at M.
Sauce’s, and held the Dauphin by the hand.
Louis XVI and his children were hungry.
As for the Queen, in the same manner, as she cared not to sleep,
she now seemed to care not to eat.
A breakfast had been prepared through the forethought of the
municipal council, but as they were a long time serving it, a
gendarme named Lapointe brought some cherries in his hat for
Madame Royale.
The royal family had likewise need of rest.
The Mayor, M. Dupuis de Dammartin, offered them hospitality;
they accepted it; only M. Dupuis de Dammartin observed to the King
that it would be just as well if the Queen and the Dauphin showed
themselves to the people.
The King made no difficulty. He showed himself first. Afterwards
the Queen appeared in her turn, holding the Dauphin in her arms.
The window of the Hotel de Ville—the only one which had a balcony
—was so narrow that the King and Queen could not both show
themselves at the same time.
A municipal officer then announced to the people that the King,
being fatigued, intended to honor the citizens of St. Menehould by
sleeping within their walls.
The carriages had already been taken to the stables, and the news
of a halt for twenty-four hours was not less agreeable to us, who
had been marching seven or eight leagues under a burning sun,
than it was to the royal family, when the National Guards from the
adjacent towns and villages, who filled the hotels and cafés, rushed
into the place, crying “Aristocrats! Traitors!” and saying that the royal
family were far too near the frontier to be allowed to halt.
 In consequence, they ordered the immediate departure of the
King and his family.
The King, having informed himself of the cause of the tumult,
said, with his usual impassibility, “Very well; let us go.”
The Queen then reappeared on the balcony holding her son by the
hand. She pointed out the National Guards to him, saying some
words in a whisper.
An inhabitant of St. Menehould, who was at an adjoining window,
assured me that the following were the words that she spoke. “Do
you see those blue toads? It is they who wish us to set out!”
It is needless to say that the National Guards wore the blue
uniform.
As the royal family crossed the hall of the Hotel de Ville, into
which opened the door of the chapel, where the prisoners had heard
mass, the Queen perceiving the captives, distributed among them
five louis—the King ten.
At two o’clock the carriages started for Châlons. From the time
that the King had been recognised he took the place of honor in the
vehicle.
MM. de Malden, de Moustier, and de Valory, sat on the box, but
they were not strapped to it as some people have said.
Not a single shout for the King, except that which Dampierre
uttered, as we have before mentioned, was used at either his arrival
or departure. The only shouts raised were “Vive la nation!” “Vivent
les patriotes!”
About nine or ten in the morning the Comte de Haus arrived at St.
Menehould, exasperated by the news of the arrest of the King.
Many persons had heard him say, “The King is arrested! We are all
lost! But the King shall know that he still has some faithful subjects!”
I have said that, after speaking to me, I had seen him go round to
the side of the horse-pond.
 As the royal carriage passed, he presented arms to the august
prisoners, after the fashion of a sentinel.
The King recognised him, pointed him out to the Queen, and
returned his salute.
M. Dampierre then put his horse to a gallop, and disappeared at
the Rue de l’Abreuvoir so as to get in advance of the King’s carriage,
stopped in the most public part of the town, at the corner of the Rue
de l’Abreuvoir, and presented arms afresh.
The King saluted him a third time.
Then pushing his horse through the crowd on the side where I
was, he approached the carriage.
It was going at this time up the Fleurion at a foot pace.
“Sire,” said he, “you see before you one of your most faithful
servants. My name is Duval de Dampierre, Comte de Haus. I have
married a lady of the House of Legur, a relative of the minister of
that name, and a niece of M. d’Allonville.”
“All these names are known to me,” replied the King; “and I am
touched at the proof of fidelity which you give me.”
This whispered conversation, after the pretence of the Comte in
presenting arms to the King on his road, was a direct provocation to
that crowd who were taking him who had wished to escape back to
Paris.
In the meantime the Comte had been gently pushed on one side,
and darting off, he disappeared in the distance.
The head of the procession reached the end of the town, and
arrived at the decline of Dammartin la Planchette.
As they left the city, M. de Dampierre reappeared, and followed
their route, keeping himself on the other side of the hedge and
ditch. He wished, by some means, to get on to the top of the King’s
carriage, from whence he could hold communication with the royal
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