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

2. Introduce self
Client industries
Chartership

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

4. ‘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?

5. 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?

6. Charlie – a case study

7. 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.

8. 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.

9. 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.

10. 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

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

12. 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

13. 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

14. 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

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

16. 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

17. 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

18. …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

19. 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

20. 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

21. Thank you
Any questions?