Human Error: The undisputed fact that people make mistakes unintentionally. It's a normal part of being human. In personal safety, it is caused mostly by inattention.
Agnosia: A neurological condition that leads to a lack of recognition of something.
So Human Error Agnosia (HEA), is the lack of recognition of human error. In other words, the mistakes that people make get attributed to systems, the physical environment, culture, inadequate leadership, etc. Seek every other cause other than anything associated with the person being able to make less mistakes.
Sufferers of HEA think safety can only be improved by eliminating hazards, altering systems, improving people’s knowledge (more induction, more training, etc), or having people care more about safety (through more or better conversations about the importance of safety). They tend to view only the positive actions of people, which is a good thing, but they ignore the fact that we evolved to learn primarily from mistakes and failures.
Neuroscience has shown that mistakes register in the Amygdala, which “turns on” the Hippocampus to generate a deeper memory, resulting in a stronger recall to avoid the mistake next time.
Here’s a practical example. In conducting training on mitigating inattention, we have collated the responses of more than 10,000 people and calculated that 53.7% of people have shut the car door on their finger once, 18.9% have done it twice but hardly anyone has done it three times. The pain of mistakes helps us re-wire our neural pathways.
HEA sufferers also regularly make statements like "Error is never a product of the individual but is always a product of the person-environment mismatch". They use Reason’s unsubstantiated quote "We cannot change the human condition, but we can change the conditions under which humans work" as an absolute, which has been disproven time and again.
Changing the conditions is a good thing to do at times, but is not the only option or the ultimate solution.
You may not be afflicted by HEA, however you could be in the camp which acknowledges human error but believes the only way to deal with it is to minimise harm once a mistake happens. Creating environments where humans can “fail-safe” is the game here.
It's certainly a step in the right direction in the short-term, but does not go far enough because people are not being helped to reduce the frequency of their mistakes long term, what we refer to as their personal error-rate.
When our actions have no consequences, we are no longer attentive of the things that could hurt us and the result is a gradual and consistent increase in error-rate. Habits which help detect things that can hurt us (e.g. look before you move or anticipate the line-of-fire), decay over time because they get used progressively less.
In our training, the following mantra resonates strongly: “The more we do for someone, the less they do for themselves”.
Any protectionism exacerbates the problem of inattention and increases personal error-rate. We understand that there are situations where protecting the employee is part of our duty of care (and a good thing), but safety seldom considers mitigating inattention by helping people to reduce their personal error-rate.
We've observed creating fail-safe environments (as opposed to helping the person reduce their personal error-rate) is not only very difficult to achieve in the real-world, but ultimately leads to the acceleration of a natural process we refer to as “danger desensitisation”.
Danger desensitisation: When our inherent sense of danger diminishes, primarily due to the lack of negative consequences from repeated behaviour. If there are no “bad” consequences for a lot of repetitions, the initial sense of danger erodes (even when the activity involves considerable risk). We all recognise this as complacency.
However, there is an approach which is aligned with our fundamental biology. It's being uncovered by brain-mapping research, so it's evidence-based and hard-nosed science. That is, if we understand how our brains really function, then we can create brain-friendly programs to help people mitigate inattention and reduce incidents.
Neuroscience measures brain activity and anatomy directly, and it tells us which parts of the brain are used to process information, which circuits are being engaged and even minute details such as which neurotransmitters are involved. It's our fundamental biology linked to our behaviours.
Neuroscience has identified the causes of inattention and provided the solutions. Work in this specialised area is referred to as Third Generation Safety, and involves creating brain-friendly programs with easy-to-use tools for mitigating inattention. You can find out more by visiting www.habitsafe.com.au.
The Man Who Mistook His Wife for a Hat – Oliver Sacks.
Assessment of Cognitive Deficit in the Brain-Injured Patient - Harold Goodglass and Edith Kaplan.