Human Factors - 1000 Lives Plus

Content © atrainability 2011

Provided in association with

The Human as Hero and Hazard

Human Factors

Trevor Dale FRAeS


Good people – trying their best


Human Factors

What do people do that makes your working day easier or more challenging?


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!


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


What if - when we start work we have:

Awareness of:

• Ourselves

• Others we work with

• How our brains work

• The changing situation


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)


•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


•Cognition errors

•Decision making faults

•Loss of situation awareness

•Communication issues

•Inappropriate team dynamics

•Lack of assertion.

Healthcare & Aviation -Common themes


Differences

Healthcare:

•Beginning to recognise human fallibility

•Collective responsibility?

•Seeks to learn from errors?

•Does not handle errors sympathetically

•Blame.


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


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.


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


MITIGATE

TRAP AVOID

Threats

Threat & Error Management


Debriefing

Check-List

and/or Asserti

on

Briefing

Threats

Checklists & Briefing


Human cognition


Short term

sensory

receptors

and stores

STIMULI

CENTRAL

DECISION

MAKER

Actions

Human cognition

Shortcut

Processing

A working guide to our brains


• Slow and hard work

• Working memory

• Method of last resort

Human cognition

ConsciousAutomatic

• Fast and effortless

• Subconscious

• Highly practiced

Human cognition


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


Attention Mechanism

•Divided Attention

•Sustained Attention

•Selective Attention

•Focused Attention

Human cognition


Sub-optimal performance

Human limitations and error


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





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


Violations

• Routine violations - work around

• Situational violations

• Thrill seeking violations.





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


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


Factors making error/violation more likely

• Fatigue

• Stress

• Illness

• Overload

• Inexperience

• Complacency.



?



?


Positives?

Experience

Training

Local culture

Physical condition

Emotional condition

Psychological state

Negatives?

Experience

Training

Distractions

Interruptions

Illness

Relationships

Fatigue

Life stresses


Beware!

Hungry

Anxious or Angry

Late or Lonely

Tired



Experiencing or witnessing rudeness/ aggression

•Causes negative emotions/ distraction

•Impairs cognition, impairs task performance

Porath & Erez (2009) Organizational Behaviour & Decision Processes,



Destructive goal pursuit


Situation awareness

• What is happening

• What are the implications

• What should or could happen next


Situation awareness

• What

• So What?

• What Next?


• 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


• 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



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.


• Closed

• Limiting

• Open

• Leading

Question Types



• 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



P-A-C-E

Probe

Alert

Challenge

Emergency.

How to be assertive



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.


Provided in association with


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


Video – stressful situation


Video – stressful situation


Thank you

Trevor Dalewww.atrainability.co.uk

http://www.atrainability.co.uk/

Documents

Human Factors - 1000 Lives Plus