By Oliver Mellors, human factors advisor at Talisman-Sinopec
Human factors is becoming a key focus area, especially in the Oil and Gas Industry where there is an ever increasing appetite to understand the human factors involved in incidents, and this can only be good news for the industry.
Rather than talk about human factors in investigations, I thought it would be interesting to discuss the human factors of incident investigations and how human factors can influence the quality and accuracy of investigations, and the ability for organisations to identify valid causal factors and remedial actions. To do this we will look at the fundamental attribution error.
In social psychology the fundamental attribution error is a well-known bias that explains the way in which people tend to evaluate other people’s behaviour.
The fundamental attribution error suggests that people are likely to assume that the behaviour of another person is due to some internal trait of that person, for instance their personality, attitude or level of intelligence. This internal focus leads to a failure to recognise or underestimate external factors that have influenced behaviour.
Interestingly, when a person is asked to reflect on their own behaviours, they often identify external factors that justify and explain their course of action.
Below is a classic example of the fundamental attribution error:
Someone cuts you off when you’re driving your car. What is your first thought? Typically, it will be along the lines of “what an idiot” or “how rude”.
Do we ever consider that the other person may have simply misjudged the manoeuvre or perhaps in a rush to pick up their child? Or perhaps we didn’t signal or were driving a little too fast?
The fundamental attribution error is extremely relevant to incident investigations as it may negatively impact on an organisation’s ability to learn; lead to flawed investigation conclusions; result in an incorrect use of ‘just culture’; produce remedial actions that do not address underlying external causes; and waste valuable resources through poor allocation, for example investing time, money and resources into behavioural based safety programmes in a hope that this will result in ‘good behaviour’ while not adequately addressing the external driving factors that produce an undesired behavioural outcome.
From a cultural perspective the fundamental attribution error may also have a negative impact on safety culture. If the workforce sees the organisation unfairly punishing individuals rather than dealing with broader external factors this could lead to a reduction in workforce engagement in safety programmes and so on.
One of the many tasks that nurses at Kaiser South San Francisco Hospital have to carry out is to administer medication to patients, a task that on average resulted in an annual error rate of 250, e.g. administering the wrong medication to 250 patients per year.
The consequence of this type of error could be deadly to a patient and as such the hospital investigated how they could improve task performance i.e. the behaviour they wanted to improve was administering the correct medication to the patient.
On investigation the hospital identified that distractions were the primary cause of errors and the remedial action directly addressed this causal factor.
Nurses used identifying medication vests which indicated to colleagues that the nurse was administering medication and should not be interrupted. This remedial action resulted in a 47 per cent decrease in medication administration error rates in a six month trial period.
Now imagine that the fundamental attribution error was committed in the above case study, with the investigation concluding that the nurses were not paying enough attention to their work, with the remedial action being to reinforce the need to “take care when administering medication” or perhaps developing a training and education program which stresses the importance of medication administration and the consequences of getting it wrong, would this have produced the same results – a 47% decrease in medication administration errors?
The fundamental attribution error is a powerful and influential bias that influences the way we see others behaviour, however the degree of its influence can be mediated by:
Simply blaming someone’s behaviour that is judged as wrong in hindsight does not explain why the behaviour occurred and what influenced their actions.
Time must be taken to understand the behaviour in the context in which it happened i.e. the goals they were trying to accomplish, the knowledge and information available to them at the time and the environment in which they were working.
What can seem like an unacceptable behaviour, in hindsight, may actually be a result of someone trying to respond to conflicting demands, poor job design or unclear responsibilities.
Performance shaping factors is a human factors term used to describe factors that increase the likelihood of human failure due to their influence on a person’s behaviour.
Raising the awareness of these factors with personnel who conduct investigations and those responsible for agreeing remedial actions can ensure these factors are afforded the appropriate level of attention.
It is also important to raise the awareness of the fundamental attribution error with personnel who conduct investigations and those responsible for agreeing remedial actions in order to support the above suggestion.
References
1. Heath. C., Health. D. (2012). Switch. How to change things when change is hard. Broadway Books.
Oliver Mellors is human factors advisor, currently working for Talisman-Sinopec providing Human factors support and guidance to Projects and Operations.
Don’t forget STRESS & FATIGUE as exacerbating human factors in the chain of causation in error, mishap or, so called, accident !!!
It is a good article, however it would be much better if we elaborate on organisational factors that could lead to human errors .in other words. system safety
A very good article that reinforces the message that a system approach to investigation is crucial. I have heard people say that incident “investigation ” is the wrong approach as it has the potential to focus on the individual. Should we use incident “review” instead?