Applied Cognitive Psychology - Leiden University (2019)

Lecture 4: Human Error

While in the past being hurt was seen as a "personality trait", it turned out that there is no difference in proneness to injury.

It is often difficult to judge a situation to be safe or not.

Kahneman:

2 systems for processing information

• System 1:
  • Fast
  • Unconscious
  • Intuitive
  • Sensitive for pictures
• System 2:
  • Slow
  • Conscious reasoning
  • Evaluate
  • Sensitive for information

System 1 always gives an immediate reaction, this is ‘uncontrollable’.

System 2 has to be activated

Unfortunately this reaction is not always good. Estimates of probability and impact are strongly influenced by:

• Saliency
• Availability
• Public outrage

Saliency

Example: 9/11 very salient, but actually much more people died in car accidents that week.

Availability

Example: While hurricane Maria got little media coverage, it was more destructive than hurricane Harvey.

Public outrage

Example: the public outrage for a gun crime is much higher than the actual hazard

James Reason

Not-intentional behavior:

• Skill-based slip (Error of commission)
• Skill-based-lapse (Error of omission)

Intentional behaviour

• Rule- or knowledge-based mistake
• Violation

Fatigue

Significant jump in risk of error after 8 hours of working

Risk of mistake is more than double after 90 minutes after break compared to 30 minutes

Expectations

Fixation on expected solutions

Confuse new problems with old problems with known solutions

Rule breaking

Who violates?

• Violators can be found at all levels of an organisation
• People may treat rules as prescriptions for others but only as guidance for themselves
• Incidents may have been caused because people followed (bad?) procedures
• Personality characteristic: sheep or wolf?

Conclusions

‘Human error’ research looked at individual behaviour and ways to ‘fix it’

Reason and Rasmussen caused a revolution in the 1980s when they categorised human error and related the categories to organisational issues

The success has been staggering in the areas where it has been applied: up to 96% less accidents

Recent developments: look at human error from a ‘complexity’ point of view

At the moment there are few practical applications, but it has potential