Hi I'm Chris I'm a medical doctor I'm going to summarize a book The Field Guide to
Understanding Human Error by Sydney Decker as the title suggests there's a spoke about
human error so unsurprisingly focuses on the airline and the medical industries his safety
making sure those few things don't go wrong or that as many things as possible go right
which includes not necessarily severe ones there's a balance to be made the old view of safety
sees people very much as a problem to control whereas the new view of safety sees people
as resources to harness this book explains the hindsight balance really well this is when you
find you already know an outcome so then you increase the estimate about its likelihood
in other words a retrospective reviewer who already knows the outcome will exaggerate their
own ability to predict and prevent this outcome the unfortunate thing is that most reviewers
are not actually aware they possess this bias when analysing adverse events
the outcome bias is really that once you know the outcome your whole evaluation and
how you evaluate the decisions that led up to that adverse outcome are changed so you're not only
more willing to judge the decisions but you're more willing to judge them harshly or more likely
and there's often a divide in an operational system between the sharp and the blunt end at
the sharp end this could be somebody driving a train or in the cockpit of a of an airline or a
surgeon on the operating in theater people are in direct contact with the safety critical process
whereas at the blunt end it's perhaps the organization that's set up to both support and
constrain that activity at the sharp end so for example this could be the airline as a whole or
the hospital the equipment vendors and regulators who may not be involved in the sharp end
make every effort to understand human error and avoid micro managing or cherry picking
you have to put yourself in the shoes of and imagine that you're there at the time and
you do not know the outcome so when you try to reconstruct something that's unfolding a dynamic
situation often there's a trickle of cues coming in and indications that could have meant
something to somebody there but given the complex factors that often in play they can be overlooked
the main thing to point out here is it's not a static or a complete situation as yours may be
when reviewing the situation it's an uncomplete incomplete unfolding and uncertain situation so
there's a few names for human error ineffective crew resource management CRM so that would be why
a plane crashed the failure to invest in common ground to coordinate operationally significant
data amongst crew members loss of situation awareness this is the failure to notice things
that in the hindsight turn out to be critical or complacency that's another word for human error
and that's the failure to recognize the gravity of a situation or to follow procedures or standards
for good practice complacency is an incorrect strategy that leads to sub-optimal monitoring
and important signals may have been missed by operator complacency
because particularly if you have a system which is automated you may find great trust that that
particular system will do the right thing so you would be less likely to double check things
non-compliance with procedures is often also referred to as human error and
failure but this book's clear to point out that labelling things like this isn't helpful
commonly it's perceived that there's a need to establish the root cause however there's
often not just one single root cause and in fact there's many factors into playing
there's a concept also known as plan continuation in which you've got a plan that you're doing and
particularly early in the process strong cues are suggesting to stick with this plan and it's a good
idea it's only later when weaker cues may come through to suggest that actually abandoning that
plan at that point would be a better idea and in hindsight it's easy to see cues from the point of
view of people at the time but not actually think how strongly they would have thought about these
you must appreciate when analysing an adverse incident you may have plenty of time a team
and months to spend studying this adverse outcome but the actual process itself may
have only taken a few moments and there's only a very small amount of time at that point
dynamic fault management is typical for event driven domains in which we must appreciate
when a situation is unfolding we have to bear in mind people only have a finite cognitive resource
and they can't put all of that into solving a situation because they also have to maintain
process integrity and by that i mean you have to keep flying the airplane or you have to keep
the patient breathing when trying to identify and fix a newly arising problem investigation
that word implies the ultimate aim is to find out what went wrong to be able to offer the one
official definitive account of what happens and really that's missing the point when it comes to
managing risk because there's often not one thing that went wrong it's often a number of factors
that are coming into play and the ultimate aim is to learn and to improve checklists and procedure
assumptions the checklists are an important safety initiative but they make these assumptions one
the environment is linear two the environment is predictable in which exact tasks and events
can easily be anticipated both in their nature and timing and thirdly the environment is controllable
and when we look at risk the book mentions several different models in which you may hear
and evaluate risks using one is the hazard triangle one is the swiss cheese model in
which things line up before a wrist can get through a chain of events which will outline the
time series quite well and a barrier model things that are put in place to stop something happening
all of these models have their own advantages but what you have to be aware of is when deciding on a
model that may only display some of the pertinent things and there may also not be a clear timeline
the thing is there's often trade-offs so what will often happen is one aspect of safety
may conflict with another part of the business process usually that will take more time and the
business process may be to do things quicker to increase productivity so that could be getting
your plane landed on time because the pilot then would receive a bonus or no bonus if they're
delayed and take another loop which perhaps is the safety of safety safer option when landing
so what you'll find is that often these little trade-offs occur in an organization and then
it's not just one or two becomes thousands of little ones in which they're no longer deliberate
trade-offs which people are thinking about but instead that individual operator is just doing
this over time and there can be an accepted pressure of risk that shifts over time and
these organizations then are putting additional pressures on for perhaps target driven results and
needing these continuing results means that shortcuts are often taken
and over time what the concept is known as a drift into failure
now drift happens insidiously and that's really that lots of little things that are cut in corners
are occurring and they keep occurring and we'll all have heard of murphy's law that's
what will could go wrong will go wrong well I'll put to you that that doesn't usually occur see the
thing with murphy's raw law is it's actually wrong what can go wrong usually goes right
and that allows us to draw the wrong conclusions so we keep potentially having little trade-offs
for be it results over safety meaning that at one point the safety margins have just been eroded
what makes a good safety culture well that's when the boss can hear the bad news
and if you're thinking about analysing safety there's often safety reports that are given
to boards and things these may not however be the best way of looking at actual safety it's
looking at what the frustrations are and the work arounds that these have led to that are occurring
on a daily basis so if you're ever doing a safety inspection don't walk around telling
people what they're meant to do instead try and understand why they work the way they do and what
seems normal for them at the time if you're ever running a safety department try to be you've got
in essence the role of being a concerned outsider who understands the inside but is independent
of others and can obtain safety intelligence from a number of sources in which you're wanting to
establish constructive involvement with management activities and the decisions and those crucial
trade-offs between safety and and efficiency that i was mentioning earlier certainly just be in or
being a practitioner in a particular field does not give you the automatic right to be a safety
officer you need to have a desire to be educated further in that field one challenge with safety is
it's more from operational value to bureaucratic accountability and those with safety as their
prime aim tend to be removed from that organization often culturally psychologically
from those who are at the sharp end so the safety people are sometimes at that blunt end
and this can lead to sharp end workers perceiving their safety documentation as simply fantasy
documents fantasy documents that bear no relation to the actual work that is being performed
try to avoid disputes in your safety department particularly if it's one role against another role
you want to have a good collaborative approach openly discussing errors so can human error go
away well the answer isn't as simple as the question because human error after all is
really an organizational problem it is at least as complex as the organization that has helped
to create it and to create safety you don't need to get rid of your system of human errors instead
you need to realize how people at all levels of the organization contribute to the creation
of safety and risk through gold trade-offs that are legitimate and desirable in their setting
so rather than trying to reduce violations aim to find out more about that gap between work as
imagined and work as done why does this gap exist what keeps it in place and how it relates
to priorities both with the workers and the overall organizational goals both stated and
Unstated responsibility mismatches are in which you give somebody less
authority to live up to the responsibility that you expect from them it's important
to identify these in your organizations and rectify them you know that your organization is
improving when it tries to learn about safety including calibrating whether its strategies
are for managing safety and risk are up to date every organization has room to improve in safety
what separates the stronger safety culture from the weak is just how large that room is
the most important thing is that the organization is willing to explore this place and to find
leverage points to learn and improve so feel free to comment below about your thoughts
like if you could like this and subscribe and I shall enjoy seeing you next time take care