What is Human Error Agnosia and Do You Suffer From It?


What’s Next After “Whack-a-Hazard” or “Whack-a-Person”?

Before we get into it, let's define what we mean.

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.