THE ART OF SCREWING UP
By Phil La Duke
DISTRACTION
According to Hallinan (and the many studies he cites), one of the key causes of errors is distraction. In today’s increasingly demanding workplace, workers are called upon to do more work with fewer resources and, sadly, more distractions. Hallinan states that even a two-second distraction can increase the likelihood of an error by tenfold. Multiply that by the multitudes of distractions we all face during the course of every workday and the virtual certainty is not just one error, but many errors.
For sales and service employees that operate out of mobile offices, an increasing number of studies have linked texting while driving with highway accidents. But it doesn’t stop there, because several other studies have shown that texting is no more dangerous than dialing a cellphone, entering information into global positioning systems, or referencing written directions.
THE MYTH OF MULTITASKING
In addition to distractions, most workers are now expected to multitask, a term coined by computer programmers to describe how a computer processes information in tandem to create the illusion of multiple tasks being completed simultaneously. Unfortunately, it truly is an illusion: Computers don’t really do two tasks at once. Instead, they rapidly switch between two or more tasks so quickly that work results appear to happen at the same time.
Studies on multitasking have shown that the human practice is equally impossible. People who appear to successfully multitask simply have greater short-term memory. Whenever a person continually switches between two or more tasks the probability of an error increases significantly. If an organization wants to reduce the dangers associated with workplace errors, it must reduce the expectation that workers will perform multiple tasks simultaneously. Sometimes more work gets done by slowing things down.
COGNITIVE OVERLOAD
More jobs now require people to keep track of an increasing volume of information. Hallinan believes that humans can only retain and retrieve a fixed amount of information and, once that amount of information has been exceeded, errors are inevitable and unavoidable. As operations continue to run ever leaner, people can expect cognitive overload to eventually lead to poor decision making, errors and injuries.
This is a red flag to safety engineers to be aware of how continually shorter process cycles and takt times could equate to a greater likelihood for mistakes and injuries associated with those foul-ups.
STRESS
Stress directly impedes our ability to make good decisions and increases the probability that people will make mistakes, from misjudgments to errors to catastrophic breakdowns. One real danger of stress is how it can cause cognitive overload by lowering the threshold at which humans can retain and act on information. Stress also reduces our ability to accurately switch between multiple tasks, making even the illusion of multitasking impossible.
But beyond its obvious effects, stress also increases the likelihood of mistake making in the subconscious mind. Our brains are designed to see patterns and to resist change. Biologically speaking, change is stupid and dangerous. If a species has found an environment ideally suited to its continued survival (ample food supply, low predators, good mating prospects, etc.), then any change can lead to disaster and extinction.
Our central nervous systems are hardwired to interpret changes in our environments as potential threats: The adrenal gland releases 37 toxins into our body that affect every major body system. This is why resisting change inside a dynamic, ever-changing environment can be equally deadly. Our subconscious minds test the safety of adapting by creating experiments . . . we act without thinking. Sometimes this unconscious exploration leads to serendipitous discovery, but other times it gets into trouble and we commit errors.
Errors represent the single greatest threat to worker safety and, what’s more, there is little that can be done to prevent them. The best we can hope for is to protect workers from errors – both their own and others. If we cannot prevent errors, how can we hope to protect workers?
Simple. We should shift our focus away from trying to prevent errors and work instead toward mitigating the severity of the injuries that might occur if someone makes a mistake. By redeploying the resources currently used to remind people to be more careful, we can significantly reduce the seriousness of the injuries that do occur.
Errors may be with us always, but the injuries associated with them need not be.
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About the Author: Phil La Duke is a partner in the Performance Assurance Practice at ERM: Environmental Resources Management, 3352 128th Avenue, Holland, MI 49424, 313-244-2525, www.erm.com. You can also follow Phil and reach him on his blogs at www.philladuke.wordpress.com.




Once again, Phil, you’re moving our thinking beyond behavior-based safety and into the realm of systems design and “toward mitigating the severity of the injuries that might occur if someone makes a mistake.”
Fred Manuele writes about designing out the “error provocative” or the complicated, multi-tasking, poor ergonomically-designed elements of work that provoke error. I think it was Todd Conklin who said that safety is the absence of (severe) consequences. One is to design tasks that help humans work more efficiently with less error. The other is to provide a safe landing.
Either way – and preferably both – I appreciate your writing on the subject. Thanks.
Rick:
Thanks for reading and thanks for your comments. I think there is a strong temptation for safety professionals to get too deeply engrossed in a particular methodology. And while behavior certainly plays a role, I don’t think we have anything close to consensus as to how we should act to manage behavior, or indeed if such thing is even possible.
Fred Manuele’s writings are important works that have brought him a lot of undeserved, in my opinion, criticism. The fact remains that many people still derive their livelihoods by selling solutions, irrespective of their effectiveness.
As for Conklin’s definition, I prefer to think of safety as the probability that one will avoid injury.