The Human as Hero and Hazard. Human Factors

Transcription

1 Provided in association with The Human as Hero and Hazard Human Factors Trevor Dale FRAeS

2 Good people trying their best

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

4 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!

5 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

6 What if - when we start work we have: Awareness of: Ourselves Others we work with How our brains work The changing situation

7 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)

8 Healthcare & Aviation -Common themes 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.

9 Healthcare & Aviation -Common themes Cognition errors Decision making faults Loss of situation awareness Communication issues Inappropriate team dynamics Lack of assertion.

10 Differences Healthcare: Beginning to recognise human fallibility Collective responsibility? Seeks to learn from errors? Does not handle errors sympathetically Blame.

11 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

12 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.

13 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

14 Threat & Error Management Threats MITIGAT E TRAP AVOID

15 Checklists & Briefing Debriefin g Check- List and/or Asserti on Briefing Threats

16 Human cognition

17 Human cognition A working guide to our brains STIMULI Short term sensory receptors and stores Processing CENTRAL DECISION Actions MAKER Shortcut

18 Human cognition Human cognition Automatic Fast and effortless Subconscious Highly practiced Conscious Slow and hard work Working memory Method of last resort

19 Human cognition Conscious control is required when: Task is novel Task is critical, difficult or dangerous A habitual task needs over-riding Prioritising competing tasks The Multitasking Myth - Loukopoulos et al

20 Human cognition Attention Mechanism Divided Attention Sustained Attention Selective Attention Focused Attention

21 Human limitations and error Sub-optimal performance

22 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

23 Human limitations and error

24 Crew must refrain from all nonessential activity, during the critical phases of a flight. Contravention of the rule implicated in many aviation disasters Sterile flight deck rule Training required to change culture

25 Human limitations and error Violations Routine violations - work around Situational violations Thrill seeking violations.

26 Human limitations and error

27 VERY UNSAFE SPACE Systemic Migration to Boundaries INDIVIDUAL BENEFITS Driving 85+ mph the illegalillegal space (for almost all of us!) Driving 75 mph- the Illegal-normal space The posted speed limit is 70 mph- the legal space Life Pressures Perceived vulnerability ACCIDENT Belief Systems. PERFORMANCE

28 VERY UNSAFE SPACE Systemic Migration to Boundaries INDIVIDUAL BENEFITS Life Pressures Only wash hands on audit days Handwashing when patient has MRSA Handwashing every patient, every time Perceived vulnerability ACCIDENT Belief Systems. PERFORMANCE

29 Human limitations and error Factors making error/violation more likely Fatigue Stress Illness Overload Inexperience Complacency.

30 Human limitations and error?

31 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

32 Human limitations and error Beware! Hungry Anxious or Angry Late or Lonely Tired

33 Human limitations and error Experiencing or witnessing rudeness/ aggression Causes negative emotions/ distraction Impairs cognition, impairs task performance Porath & Erez (2009) Organizational Behaviour & Decision Processes,

34 Destructive goal pursuit

35 Situation awareness What is happening What are the implications What should or could happen next

36 Situation awareness What So What? What Next?

37 RED FLAGS Situation awareness 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.

38 Team communication and assertiveness Barriers to Communication Listener s capacity, workload Voice, accent, tone, volume, etc. Noise Stress Interruption Culture, status, loss of face Authority gradient.

39 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.

40 Team communication and assertiveness Question Types Closed Limiting Open Leading

41 Team communication and assertiveness Barriers to assertion Hierarchy-Power Distance Lack of Common Mental Model Don t Want to Look Stupid Not Sure I m Right Fear of Retribution.

42 Team communication and assertiveness How to be assertive P-A-C-E Probe Alert Challenge Emergency.

43 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.

44 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

45 Video stressful situation

46 Video stressful situation

47 Thank you Trevor Dale