The Psychology of ‘Human Error’: Why do people get things wrong? Claire Philp ©Human Applications Ltd

Introduce self Client industries Chartership

Risk Management Consultancy Midlands Health & Safety, Physical Ergonomics, Usability Introduce HA Client industries Sort of people we employ

‘Human error’ – what do we mean? In a safety context this means people working in an unsafe manner Add some nod to Hollnagel ‘performance variation’ here?

Definition “people operating within our systems in a way which we do not desire” In a safety context this means people working in an unsafe manner Add some nod to Hollnagel ‘performance variation’ here?

Charlie – a case study

Human error massively overused in the media, generally with very little detail or explanation beyond the label. New articles every day implicate human error in major disasters and events. Used as an end point. Fulfils public appetite for somebody to blame. Outside of professional H&S practice, widely misunderstood and emotive term.

The ‘Human Error’ problem ‘Human error’ provides the public with a simple headline to draw a line underneath major disasters But beneath this banner the lessons and the subtleties are lost Despite the well-documented problems with the use of the term, ’human error’ doesn’t seem to be going anywhere fast There are still many conflicting opinions in the safety world around the use of the term ‘human error’. Often overly simplistic of human behaviour, cognition and psychology. In a room full of safety practitioners there will be a range of opinions. The conversation will go on into the future - this isn’t what this session is about. The term ‘human error’ is here to stay, for now We offer an almost “if you can’t beat ‘em, join ‘em” approach – to address some of the shortfalls of current public domain understanding of human error, and to make businesses smarter and safer as a result.

How do we talk to clients about ‘Human Error?’ We need to maximise organisational learning Organisations need to respond appropriately We need to move the focus away from blame We need to drive behaviour change What we are concerned with is how we can enhance the current level of understanding in industry and affect real behavioural change as a result. We will look at a simple tool for talking to normal managers about human error – in a way that really benefits them and their employees.

Let’s play a game You are in an area where wearing a high visibility jacket is mandatory You see someone in the area not wearing a jacket Why? I’ve just walked onto site and you’re not wearing a high vis Why? Call out answers No repeats

Slips/Lapses I knew the rule I didn’t intend to break the rule Something went wrong

Knowledge-based errors I didn’t know the rule Or I thought I knew the rule but I was wrong Or I applied the wrong rule in this circumstance I didn’t intend to break the rule

Power station Green – off Red – on There’s obviously some confusion – this is not a consistent rule Also can use the keypad numbers example; Keyboards start 1 bottom left Phones start 1 top left

Violations I knew the rule I intentionally broke the rule Violations aren’t just negative (Reason) They can be really interesting They tell us a lot about our procedures, equipment, where our people have to make do, where are rules aren’t working Recognises positive variability – Hollnagel - in this context are violations made for good reasons which actually identify better ways to do things which do not compromise safety This is at odds with the way we desire (p;rocedure), but may not always be negative

Error categorisation Adapted from Rasmussen and Reason’s categories Small number of categories Simple language

Human error and accident investigation Understanding human error is important in accident investigation We expect managers to make sound judgements We are all susceptible to conscious and unconscious biases A lack of understanding compounds this How many managers still believe there are accident-prone people, and if they could fire them all they would have no accidents? A lack of human error understanding leaves us with only our biases with which to make judgements

Examples of Biases Hindsight bias - once you know the outcome, the failures are obvious and seem avoidable Confirmation bias – if you investigate with a pre-formed idea of what you think happened, you will only notice the evidence that supports that idea Attribution bias – overemphasising personality factors in others’ mistakes and underemphasising situational factors (vice versa when looking at their own mistakes) Availability bias - certain vivid memories, experiences, facts come to mind more easily to drive our decision making

…And more Anchoring Gambler’s fallacy Primacy, recency and serial effects Sunk cost effect Heuristics Tacit knowledge More psychological pitfalls that can inform our decision making

Why is this important? A simple tool so that anyone can improve their understanding beyond the term ‘human error’ Appropriate responses and controls vary by error ’type’ Tool enhances the way managers approach non-compliance More effective responses drive behavioural change in employees No more re-training violators! No more wasted money that isn’t tackling the problem

More effective accident investigation With a simple framework for identifying types of errors and responding appropriately, our investigations are less vulnerable to the biases of the investigator

Thank you Any questions?