make lots of errors we make errors every
day and psychologists like me are
interested in errors and understanding
where they come from the psychologist
James reason asked people to keep
Diaries of their errors and my favorite
example from his work was a woman who is
rushing out to work in the morning a
very good way to make errors rushing and
she had her earrings in one hand and she
had the dog biscuits in the other and
she fed the dog and the next thing she
is at the mirror trying to attach to dog
biscuits to her ears not very good for
the earrings not great for the dog but
not a major disaster but we can make
errors at work yet we have skills kind
of hidden skills to help us avoid error
and catch error these are the skills I’m
going to talk to you about and I’d like
you to think about maybe you have some
of these skills in your job and because
I don’t know what your job is let me
take an example from driving so you may
have been driving here on this snowy
morning an unfamiliar area what are you
doing you’re driving operating the car
but you’re also gathering information
watching the traffic looking at the road
surface maybe you’re thinking where do I
make a turning and if in a few minutes
ahead you may be asking your passenger
to help you navigate you may be asking
your children to be quiet because you’re
aware they’re beginning to distract you
and what you’re using here are thinking
skills and social skills that are not
part of the technical driving skills but
they’re skills that help us work
efficiently and they’re very good skills
for catching error and these skills are
called non-technical skills so if we
take
those non-technical skills are now
squirrel where did they where did these
skills come from this is where they came
from they came or where they came from
where they were first identified was the
world of aviation and from the big
aviation accidents the ones that really
had no technical causes this is a
picture of Tenerife there were a number
of accidents in the 1970s and the 1980s
that really puzzled investigators
because they were technically competent
crew there were no main technical
problems with the aircraft and still we
had these kinds of crashes the jumbo
jets at Tenerife that collided something
to do with communication the Florida
crew became distracted by a little
problem and failed to notice they had a
great big problem and flew into the
ground in England we had a flight with a
plane with one engine on fire and
accidentally the pilots turned off the
other engine and now we have no engines
and so the plane crashes so these were
very puzzling to the investigators why
why were we having these kinds of
accidents and how could we find out
where they were coming from because they
were just being called pilot error and
here’s the answer the answer was hidden
in the cockpit voice recorder in the
black box this is a black box you can
see it’s orange very nice Dutch color
orange but this is so we can find the
black box and in there’s a recorder and
when they listen to the recordings they
found all kinds of behavior patterns
that were contributing to error or were
meaning the errors weren’t getting
caught so there were things to do with
the way the pilots work together things
to do with decision making things to do
with poor leadership things to do with
communication all in the voice
recordings and so they realize that
there were these other skills that
pilots needed and they called these
these non-technical skills and at this
point they began to get the aviation
psychologist to work in the simulators
to start really understanding what these
behaviors were that they were going to
have to bring into the pilots tree
one of these was a situation where
co-pilots as in tenerife did not speak
up very forcefully to the captain when
they thought there might be a problem
with the flight and they could hear this
on the voice recording they set up a
simulation and they asked the captain’s
to feenin capacity take very bad
decisions and they were watching the
behavior of the copilot’s and they were
alarmed by the findings because what
they saw was that the copilot’s were
taking a long time to challenge the
captain even if they challenged them at
all even when they were clearly
concerned that something was going wrong
and this was due to the status hierarchy
the authority gradient a more senior
person and the more junior person
cautious and careful about speaking up
one of the psychologists said at the
time co-pilots would rather die and
challenge a captain this is not a
situation that could continue so they
began to bring in special training
across the set of these skills including
assertiveness for pilots but surprising
if you’ve ever seen pilots to think that
they need assertiveness training and not
enough to train the copilot’s to be
assertive you have to train the
captain’s to listen to the copilot when
the copilot is trying to speak up
so this was a whole new way of thinking
a whole new kind of training that we
brought into aviation to train these
non-technical skills these are the main
catagories and underneath these are all
these behaviors about not listening not
speaking up not working well together
and the special kind of training they
brought in an aviation is called crew
resource management and you may be aware
that pilots by law in each country have
to have this crew resource management
training they have it at the start and
they have it every year
and now they have their skills their
non-technical skills assessed as well as
their technical skills and I worked in a
European project with some Dutch pilots
developing a system for rating pilots
known technical skills that’s my
interest in this in this particular area
but it’s not just pilots who need
skill there are other high-risk work
environments this being one of them
healthcare I also work a bit on patient
safety and there have been some big
accidents where patients have died
because of error in one case in 2005 a
woman called Elaine Bromley went into
hospital for a minor procedure
mid-thirties mother of two small
children anesthetist put her to sleep
tried to make the intubation but have a
big problem getting the tube down and
they struggled to try and do this and
they start to lose track of time and all
the time her oxygen levels are too low
for her brain the nurses to nurses
become concerned try to intervene and
are waved away by the by the doctors who
continue to focus on their tasks
eventually they give up she said to the
recovery room
in fact she never recovers and her
husband ten days later has to switch off
her life support machine why I’m telling
you this story is because Martin Bromley
her husband is a pilot he’s an airline
captain and he asked for an independent
report into his wife’s death and when he
did this the report came back and it was
full of failures and non-technical
skills losing track of the situation
losing track of the time not listening
to people who are trying to tell you
there’s a problem not working together
as a team bad decisions and so he has
been working ever since to try and bring
this non-technical skills training into
health care because the doctors and
nurses have been getting no training of
this kind even though they work in a
high-risk environment and our work in
Scotland has been working between
psychologists surgeons anaesthetists and
nurses to design systems and design
training for bringing in non-technical
skills but they can use for training in
the healthcare environment particularly
in the operating room which is quite
high risk at times and we now see other
industries starting to bring in these
non-technical skills the real industry
the shipping industry the mining
industry
because they recognize this is a missing
piece that they need to improve safety
and efficiency so what I am asking you
is to think about for your job maybe
there’s some non technical skills
required there that have never really
been identified the best people have
always used them but they’re not
documented anywhere the trainees find
these difficult and slow to learn and to
finish with to give you an example
because I said at the beginning error is
very common I’d like to share with you
an error I made in healthcare I was
working in a in a hospital when I was a
student I was an assistant and a
geriatric ward with elderly patients my
first day at work my nurse came up to me
and gave me a tree and on the tree were
20 little pots 20 little containers and
in each container was a pair of
artificial teeth false teeth belonging
to the patients in the ward and they
said to me can you clean these teeth I
thought this is a pretty horrible job to
be cleaning other people’s dirty teeth
so I take them to the sink and I think
how could I do this efficiently so I
fill the sink with water and I tipped
all the pots of teeth into the sink and
I picked up the first pair right pleased
with myself because I like this
efficiency I’m brushing the first teeth
and I go to replace them and I look and
there’s no name on the teeth the names
are on the pots so now I have a sink
with 20 pairs of teeth and we don’t know
who the teeth belong to this is clearly
not a major problem it was a little bit
uncomfortable in the ward there were
some very strange smiles in the ward for
a day or two until the teeth were
reunited with the correct owners the
nurses were not pleased with me it
really was the end of my nursing career
rather
the beginning of it and it was a failure
in situation awareness not thinking
ahead of the implications of the action
I was taking making a very bad decision
probably also not listening to any
instructions that I had been being given
so not a major failure not a disastrous
dangerous error but still an error the
typical kind of thing that happens every
every day in everybody’s life and in
everybody’s work so what I think is an
idea worth spreading is that we look at
the non-technical skills not just for
the high-risk jobs but for lots of jobs
because I think understanding better
these hidden skills these cognitive
skills these social skills can help to
improve efficiency help to reduce error
and maybe keep things a little bit safer thank you very much