Regular
readers of this blog know that I am an unabashed champion of the safety
strategy know as Threat and Error Management (TEM). Simply stated, TEM is a perspective that
pursues a safe operation by identifying threats and errors then preparing for
and correcting them to avoid negative consequences. There is no procedure for TEM. There is no recipe to follow. It is a mindset. It is a continual critical assessment of the
situation. To quote Gerry Bruggink (1917
– 2005), former Chief of Human Factors for the NTSB, “most accidents are caused
by uncritical acceptance of easily verifiable assumptions.” TEM calls for evaluating one’s assumptions
and continual monitoring of the dynamic situation to be aware of
changes. In aviation, the dynamic situation always includes
errors in human performance.
Human
cognition is incredibly complex and very difficult to understand. The results of free will can be hard to
predict and can be easily subverted. For
decades Madison Ave. has used this fact to manipulate consumers. Illusionists routinely convince people they
see things that don’t exist or didn’t happen.
People still choose to stick their hands in a running lawnmower is spite
of sophisticated “safety” devices.
What
causes pilots and others in highly technical occupations to abandon or reject
best practices and engage in risky behavior in spite of their training? It starts with a conscious or an unconscious
assumption that “it can’t/won’t happen to me”.
When
facilitating human factors workshops I often show a picture of a man engaged in
obviously risky behavior. He is sitting
under his truck, held precariously by a couple pieces of wood, welding on the
gas tank. I ask the participants to
comment. The response is universally
quite judgmental. A "Darwin Award" is usually suggested. Next, I ask the class
if they feel that driving while talking or texting on a smartphone can be
dangerous. They answer in the
affirmative. Finally, while raising my own
hand, I ask who has driven while talking or texting. “What is the difference between us and the man in the picture?”, I ask.
Evaluating the origins of our own behavior and that of others is one of the biggest
obstacles to the adoption and integration of TEM into airline operations. This difference between how we interpret the cause of our
actions or errors and how we see it in others is known as Actor-Observer Asymmetry or
Bias. This was first proposed by social
psychologists Edward E. Jones and Richard E. Nisbett in 1971. They concluded, “The actor may simultaneously
view his own personality as being more unique than it is and his own behavior
being more appropriate to given situations than is the behavior of others.” This trait is not a disorder. It is a “normal” human characteristic. However, like many human traits like distractibility, it is the classic Catch-22. “I'm only OK if I know I am not OK..”
TEM
requires that we see ourselves as both actors and observers. We need to see in ourselves our uniqueness as
well as our sameness with those we observe.
If we actually thought we would crash our car while talking on our
mobile phone we wouldn’t do it. At the
same time we absolutely accept the premise that others might crash and
therefore consider it an unsafe practice for the general population. We believe that when we arrive home safely
after talking on our mobile phone it is because of our ability and not
that we were perhaps lucky. Things that
may be seen as a threat in the abstract are not a threat for me practically.
During the workshops we often do case studies on noteworthy accidents. I am always intrigued by the "Actor Observer Bias" demonstrated by some participants in these case studies. The "I would never do that." expression on their face is easy to recognize. It is difficult for most pilots to put themselves
in the position of the accident/incident crew.
Actor Observer Asymmetry is a major obstacle to error recognition
and avoidance. As obvious as it sounds,
it’s difficult to avoid errors you don’t think you’re likely to make. All humans make errors. Let me say that again, all humans make mistakes. It is impossible to avoid all of them. However, it is possible to recognize and
correct errors before there is a consequence.
Therefore, it is also necessary in these workshops to demonstrate how
easy it is to introduce errors into human cognition. There are many simple “parlor tricks” to demonstrate, "to err is human". These help to
reduce the asymmetry between the class participant (observers) and the crew in the case
study (actors).
Although aircraft have become more reliable through advanced technology, the human brain hasn't changed since Kitty Hawk in 1903. There are many lessons that can be learned from 110 years of aviation, but only if we believe those lessons apply to ourselves, not just the other guy.
Although aircraft have become more reliable through advanced technology, the human brain hasn't changed since Kitty Hawk in 1903. There are many lessons that can be learned from 110 years of aviation, but only if we believe those lessons apply to ourselves, not just the other guy.
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