The Human Contribution

Unsafe Acts, Accidents and Heroic Recoveries

James Reason

• Publisher: CRC Press
• Year: 2017
• ISBN:
  9781351888103
• Edition: 1
• Topic: Technologie et ingénierie
• Subtopic: Santé et sécurité au travail

This book explores the human contribution to the reliability and resilience of complex, well-defended systems. Usually the human is considered a hazard - a system component whose unsafe acts are implicated in the majority of catastrophic breakdowns. However there is another perspective that has been relatively little studied in its own right - the human as hero, whose adaptations and compensations bring troubled systems back from the brink of disaster time and again. What, if anything, did these situations have in common? Can these human abilities be 'bottled' and passed on to others? The Human Contribution is vital reading for all professionals in high-consequence environments and for managers of any complex system. The book draws its illustrative material from a wide variety of hazardous domains, with the emphasis on healthcare reflecting the author's focus on patient safety over the last decade. All students of human factors - however seasoned - will also find it an invaluable and thought-provoking read.

PART I

Introduction

Chapter 1

The Human Contribution: Hazard and Hero

Introduction

The purpose of this book is to explore the human contribution to both the reliability and resilience of complex well-defended systems. The predominant mode of treating this topic is to consider the human as a hazard, a system component whose unsafe acts are implicated in the majority of catastrophic breakdowns. But there is another perspective, one that has been relatively little studied in its own right, and that is the human as hero, a system element whose adaptations and compensations have brought troubled systems back from the brink of disaster on a significant number of occasions.

After studying human unsafe acts within hazardous enterprises for more than three decades I have to confess that I find the heroic recoveries of much greater interest and – in the long run, I believe – potentially more beneficial to the pursuit of improved safety in dangerous operations. Since most observations of people in high-risk systems are event-dependent; that is, they generally emerge from well-documented accident investigations, it is inevitable that we should know far more about the hazardous human than the heroic one.

But there is a stark contrast between unsafe acts and these intrepid recoveries. Errors and violations are commonplace, banal even. They are as much a part of the human condition as breathing, eating, sleeping and dying. Successful recoveries, on the other hand, are singular and remarkable events. They are the stuff of legends. But these abilities are not unattainable. A few people are born heroic, but most of us can acquire the skills necessary to give a better than an evens chance of thwarting a disaster scenario. However, it must be acknowledged that such heroism is not necessarily an enduring characteristic. Even the best people have their bad days.

The Structure of the Book

The book is organised into five parts. The present chapter introduces the subject matter. Chapter 2 offers an inside-out guide to being a mind user. We all know what it feels like to have a mind, but we don’t always appreciate that ‘feelings-of-knowing’ can sometimes be very misleading. There are things you think you know about how your mind works, but don’t. And there are things you think you don’t know, but actually do. To realise your mind’s full potential, you need to understand when these feelings of knowing (or not knowing) are useful and when they are deceptive. I will be discussing these mental processes from a user’s perspective: from the inside looking out, not from the outside looking in – hence an inside-out view.

I’m not denying the intimate connection between the mind and the brain. It is just that this book is not about brain scans and neural wiring diagrams. While modern techniques can tell us a great deal about the brain’s structure and function, they never wholly capture the moment-to-moment experiences of being a mind user, and none can track all of the subtle interactions between the conscious and automatic control processes. And that is what interests me here.

Part II is concerned with unsafe acts: errors and violations, and how they are perceived by those upon whom they impact. Unsafe behaviour may be less fascinating than heroism, but it is no less important.

Chapter 3 focuses on the nature and varieties of human error. In order to limit the damaging occurrence of errors and improve their chances of detection and recovery, we need to understand something of their cognitive origins and the circumstances likely to promote them. This understanding can translate into ‘error wisdom’ at the sharp end – what has been termed ‘individual mindfulness’, to be discussed in Part V.

Chapter 4 deals with rule-related behaviour. I begin by considering the various types of violation, and then discuss the social, emotional and systemic factors that lead people to choose not to comply with rules, regulations and safe operating procedures. However, such acts of non-compliance are not universally bad. They can have beneficial as well as unwanted consequences. This becomes evident when we look in detail at the 12 varieties of rule-related behaviour.

Chapter 5 examines a number of different perceptions of human unsafe acts, of which the two most dominant are the person and the system models. Each has its own theory of how these unsafe acts arise, and how they might be remedied and managed. The person model, asserting that errors originate within the minds of the people concerned, is intuitively appealing and still holds sway in many domains. However, over recent years, the system model has gained increasing ascendancy. This argues that the people on the frontline are not so much the initiators of bad events as the inheritors of long-term system failings. My thesis is that the extremes of both views have their shortcomings. We need to strike a balance between the two.

Part III deals with accidents and their investigation. One fact that lends strong support to the system approach is that similar situations keep provoking the same kinds of unsafe acts in different people. These recurrences, discussed in Chapter 6, indicate that a substantial part of the problem is rooted in error-provoking situations rather than in error-prone people. A primary function of error and incident reporting systems is to identify these ‘error traps’. Eliminating them becomes a priority task for error management programmes.

Complex hazardous systems are subject to two kinds of bad event: individual accidents, resulting in limited injury or damage, and organisational accidents that occur relatively infrequently but whose consequences can be both devastating and far-reaching. One of the features that discriminates between these two kinds of adverse event is the degree of protection available against the foreseeable hazards. Whereas individual accidents usually result from the failure of very limited safeguards (or their absence), organisational accidents involve a concatenation of breakdowns among many barriers, safeguards, and controls. It is this combined failure of the many and varied ‘defences-in-depth’ that characterises the organisational accident and it is this type of event that will be the main concern of this book.

Chapter 7 focuses on two pioneering accident investigations that fundamentally changed the way the human contribution to bad events is regarded. In particular, they spelled out how unsafe acts and latent organisational conditions (resident pathogens) interact to breach the multi-layered system defences. It also traces how the emphases of investigations have shifted from technical and human failures at the sharp end to examining the effects of ‘upstream’ factors such as organisational processes, safety culture, regulation and even the economic and political climate. It is suggested that perhaps the pendulum has swung too far towards identifying causal factors that are remote in time and place from the local events. This chapter also looks at some of the problems facing accident investigators, and others who seek to make sense of the past. One such problem is the failure to differentiate between conditions and causes, thus falling foul of the counterfactual fallacy

For these and related reasons, it is argued that continual tensions between production and protection lead to resident pathogens being seeded into the system, and this is true for all systems. But such organisational shortcomings are conditions rather than causes. Although they contribute to defensive failures, they are not in themselves the direct causes of accidents. The immediate triggers for such bad events are local circumstances: human and technical failures that add the final ingredients to an accident-in-waiting that may have been lurking in the system for many years. All systems, like human bodies, have resident pathogens. They are universals. It is usually only the proximal factors, immediate in both time and space to the accident, that distinguish between a system suffering a catastrophic breakdown and those in the same sphere of operations that do not.

Up to this point, the book deals mainly with the human as a hazard. In Part IV, we look at the other side of the coin: the human as hero. Eleven stories of heroic recovery are told. They are grouped into four chapters:

• Chapter 8 (training, discipline and leadership) examines two military case studies: the retreat of Wellington’s Light Brigade on the Portuguese–Spanish border in 1811; and the retreat of the US 1st Marine Division from the Chosin Reservoir in 1950.

• Chapter 9 (sheer unadulterated professionalism) deals with Captain Rostron and the rescue of the Titanic survivors in 1912; the recovery of Apollo 13 in 1970; the Boeing-747 Jakarta incident; the recovery of the BAC 1-11 in 1990; and surgical excellence as directly observed in 1995–96.

• Chapter 10 (luck and skill) looks at the near-miraculous escapes by the ‘Gimli Glider’ on the edge of Lake Winnipeg in 1983 and United 232 at Sioux City in 1989.

• Chapter 11 (inspired improvisations) discusses General Gallieni and the ‘miracle on the Marne’ in 1914; and the saving of Jay Prochnow lost in the South Pacific by Captain Gordon Vette in 1978.

• What, if anything, did these heroes have in common? Chapter 12 seeks to identify the principal ingredients of heroic recovery.

Part V (Achieving Resilience) has two chapters. Chapter 13 elaborates on Karl Weick’s notion of ‘mindfulness’. In its broadest sense this involves intelligent wariness, a respect for the hazards, and being prepared for things to go wrong. Mindfulness can function both at the level of the frontline operators and throughout the organisation as a whole. The former we term ‘individual mindfulness’ and the latter ‘collective mindfulness’. Both are necessary to achieve enhanced systemic resilience. We can’t eliminate human and technical failures. And no system can remain untouched by external economic and political forces. But we can hope to improve its chances of surviving these potentially damaging disruptions in its operational fortunes.

The last chapter deals with the search for safety, the broadest part of the book’s spectrum. Two models of safety are described: the safety space model and the knotted rubber band model. The former operates at the cultural and organisational levels; the latter has a more tactical focus and deals with keeping some continuous frontline process within safe boundaries. Together, they have implications for re-engineering an existing culture to improve safety and resilience. Or, to put it another way, this concluding chapter is concerned with the practical measures necessary to achieve states of both individual and collective mindfulness.

About the Book

I should end this introduction by saying something about the readership and style of the book. Perhaps I should begin by saying what it is not. It is not a scientific book, even though it touches upon scientific and technological issues. It is written in the first person. That means that these are my personal views – and prejudices. It is written for real people, even though academics and students may find parts of it of interest. But it does not require any prior knowledge of academic psychology, although these issues are touched upon in the first chapters. Nor is it a ‘how-to-do’ book. If there is any way of describing the content, I would say it was about the philosophy of managing complex hazardous systems. Philosophy is a daunting word, but in this book it simply means a way of thinking about the issues. In short, it is a way of confronting the problems of conducting a hazardous operation so that you keep your risks as low as reasonably practicable and still stay in business. It is this latter injunction that, for me, is the most important one.

Chapter 2

A Mind User’s Guide

After using a mind for seventy years, I realise that I know very little about it, and the older I get the more this conviction grows. It is true that after nearly forty years of researching and teaching psychology, I do have an inkling of what I do and don’t know. It is also the case that I have some understanding of what I think I know, but really don’t. And, if I ask myself the right questions, I can occasionally come up with things that I didn’t think I knew, but actually did. For all that, though, much of my mental functioning remains secretive, seemingly out of reach and full of surprises.

But – you might be thinking – Sigmund Freud told us that over a hundred years ago.¹ So what is new? Quite a lot, as I will hope to show later. Freud is closely linked with the idea of an unconscious mind, but he did not invent the term, nor is his rather narrow view of the unconscious widely accepted by contemporary psychologists. I do not reject the idea of an unconscious mind – indeed, its existence is the main reason for including this chapter but I do dispute the strict Freudian interpretation of its role in our mental lives.

My purpose here is to make you, the everyday mind user, more familiar with the mysteries of your own mental life, and once in a while – to tell you something that you did not already know. This chapter is also intended to act as an introduction to the discussion of errors and violations in the next two chapters.

Tip-of-the-Tongue State

Let’s start with a commonplace experience. There’s nothing quite like the ‘tip-of-the-tongue’ (TOT) state to expose the subtleties of knowing and not knowing the things that go on in your own mind. A TOT state begins with an attempt to retrieve from memory something that you are sure you know, but then the search fails to yield an immediate, felt-to-be-correct response. Instead, it produces a name or a word that you recognise as being ‘warm’, but you also know that this is not the sought-for item.

When you persist with the search, the same wrong item keeps coming to mind in an irritatingly obtrusive fashion...