Download - Human Factors - 1000 Lives Plus
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The Human as Hero and Hazard
Human Factors
Trevor Dale FRAeS
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Good people – trying their best
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Human Factors
What do people do that makes your working day easier or more challenging?
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Human Factors
What do people do that makes your working day easier or more challenging?
Communication problems
Surprises & Changes
Appropriate resources – people and equipment?
Time pressures? Stress?
Interruptions & Distractions
Personality clashes
People!
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What if - when we start work:
• We could leave our personal stresses behind
• Leave our negative personality traits behind
• Understand everyone else‟s point of view
• Avoid possible problems
• Remember everything we‟ve ever learned
• Learn from our and others‟ mistakes
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What if - when we start work we have:
Awareness of:
• Ourselves
• Others we work with
• How our brains work
• The changing situation
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Human Factors - Definition
“Human factors” encompasses all those factors that can
influence people and their behaviour. In a work
context, human factors are the environmental,
organisational and job factors, and individual
characteristics which influence behaviour at work.
Based on UK Health and Safety Executive, Reducing error and influencing
behaviour, HSG48, HMSO (2005)
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•Great technical skill
•High reliability
•Work long hours – fatigue
•Regarded with awe and respect
•Trusted – their lives – our hands
•Number of safety opportunities
•Capable of harming similar numbers.
Healthcare & Aviation -Common themes
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•Cognition errors
•Decision making faults
•Loss of situation awareness
•Communication issues
•Inappropriate team dynamics
•Lack of assertion.
Healthcare & Aviation -Common themes
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Differences
Healthcare:
•Beginning to recognise human fallibility
•Collective responsibility?
•Seeks to learn from errors?
•Does not handle errors sympathetically
•Blame.
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Differences
Aviation:
• Recognises human fallibility – expects error
• Seeks to learn from errors –feeds back to training
• Handles errors sympathetically but not violations
• Disciplined trained teamwork
• Continuing technical & non-technical training
• Regular assessment - 3 times per year
• Briefing & Checklists
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Culture
After a rule has become common knowledge, if one
member of the team is seen violating that rule,
then the other team members feel authorised to
bring this to the attention of the violator.
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Counter-Heroism
• Discourage individuals from
devising makeshift
adjustments in response to
hazards and adverse events
• Promote a less deferential, less
hierarchical workplace:
Senior staff feel less pressured to
make ad hoc adjustments in
response to system failures
Junior staff feel less awkward
about raising concerns
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MITIGATE
TRAP AVOID
Threats
Threat & Error Management
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Debriefing
Check-List
and/or Asserti
on
Briefing
Threats
Checklists & Briefing
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Human cognition
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Short term
sensory
receptors
and stores
STIMULI
CENTRAL
DECISION
MAKER
Actions
Human cognition
Shortcut
Processing
A working guide to our brains
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• Slow and hard work
• Working memory
• Method of last resort
Human cognition
ConsciousAutomatic
• Fast and effortless
• Subconscious
• Highly practiced
Human cognition
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Conscious control is required when:
•Task is novel
•Task is critical, difficult or dangerous
•A habitual task needs over-riding
•Prioritising competing tasksThe Multitasking Myth - Loukopoulos et al - 2009
Human cognition
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Attention Mechanism
•Divided Attention
•Sustained Attention
•Selective Attention
•Focused Attention
Human cognition
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Sub-optimal performance
Human limitations and error
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High risk situations:
•interruptions and distractions
•tasks required out of normal sequence
•unanticipated new tasks arise
•interleaving multiple tasks.
The Multitasking Myth - Loukopoulos et al - 2009
Human limitations and error
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Human limitations and error
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Sterile flight deck rule
• Crew must refrain from all
nonessential activity, during
the critical phases of a flight.
• Contravention of the rule
implicated in many aviation
disasters
• Training required to change
culture
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Violations
• Routine violations - work around
• Situational violations
• Thrill seeking violations.
Human limitations and error
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Human limitations and error
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PERFORMANCE
VE
RY
UN
SA
FE
SP
AC
E
Belief
Systems.
Life Pressures
The posted
speed limit is
70 mph- the
„legal‟ space
INDIVIDUAL BENEFITS
Driving 75
mph- the
„Illegal-normal‟
space
Driving
85+ mph –
the „illegal-
illegal‟ space
(for almost
all of us!) Perceived
vulnerability
ACCIDENT
Systemic Migration to Boundaries
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PERFORMANCE
VE
RY
UN
SA
FE
SP
AC
E
Handwashing –
every patient,
every time
Belief
Systems.
Life Pressures
INDIVIDUAL BENEFITS
Handwashing
when patient
has MRSA
Only wash
hands on
audit daysPerceived
vulnerability
ACCIDENT
Systemic Migration to Boundaries
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Factors making error/violation more likely
• Fatigue
• Stress
• Illness
• Overload
• Inexperience
• Complacency.
Human limitations and error
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?
Human limitations and error
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?
Human limitations and error
Positives?
Experience
Training
Local culture
Physical condition
Emotional condition
Psychological state
Negatives?
Experience
Training
Distractions
Interruptions
Illness
Relationships
Fatigue
Life stresses
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Beware!
Hungry
Anxious or Angry
Late or Lonely
Tired
Human limitations and error
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Experiencing or witnessing rudeness/ aggression
•Causes negative emotions/ distraction
•Impairs cognition, impairs task performance
Porath & Erez (2009) Organizational Behaviour & Decision Processes,
Human limitations and error
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Destructive goal pursuit
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Situation awareness
• What is happening
• What are the implications
• What should or could happen next
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Situation awareness
• What
• So What?
• What Next?
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• Disagreement between two sources of information
• Fixation on single task to exclusion of all else
• Confusion or uncertainty not resolved
• Failure to adhere to accepted practice
• Failure to comply with warning signs
• Failure to communicate effectively
• Displacement activity
• Leading questions.
RED FLAGS
Situation awareness
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• Listener‟s capacity, workload
• Voice, accent, tone, volume, etc.
• Noise
• Stress
• Interruption
• Culture, status, loss of face
• Authority gradient.
Barriers to Communication
Team communication and assertiveness
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Team communication and assertiveness
Closed Loop Communication
• Team member makes a request, using the name of another team member
• The team member being addressed responds verbally to confirm that they are doing what was asked.
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• Closed
• Limiting
• Open
• Leading
Question Types
Team communication and assertiveness
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• Hierarchy-Power Distance
• Lack of Common Mental Model
• Don‟t Want to Look Stupid
• Not Sure I‟m Right
• Fear of Retribution.
Barriers to assertion
Team communication and assertiveness
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P-A-C-E
Probe
Alert
Challenge
Emergency.
How to be assertive
Team communication and assertiveness
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Summary
• We cannot multi-task
• The brain has handy short-cuts but these can cause problems
• Tasks are either conscious or automatic
• Pattern matching can be good or bad.
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Blame Culture?
It is important not to blame individuals for what went wrong but to understand why,
what they did at the time, made sense to them.
„Just Culture’ - Dekker - 2007
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Video – stressful situation
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Video – stressful situation
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Thank you
Trevor Dalewww.atrainability.co.uk