Dr. Steven Shorrock, a chartered psychologist and human factors specialist, discusses the intricate relationship between human behavior and safety in high-stakes environments. He emphasizes the shift from analyzing errors to adopting a balanced view of both successes and failures. The conversation dives into the concept of 'just culture' and the complexities of neurodiversity, advocating for understanding strengths in conditions like ADHD. Shorrock also critiques conventional error analysis, proposing a new approach to understand cognitive errors in critical decision-making contexts.
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Path to Aviation Safety
Dr. Steven Shorrock's interest in human behavior stemmed from being autistic and needing to decipher social cues.
This led him to psychology, human factors, and eventually a PhD in aviation safety, focusing on human error.
insights INSIGHT
Error Taxidermy
Human error analysis often focuses on dissecting incidents and classifying errors, neglecting systemic factors.
This "error taxidermy" approach overlooks the influence of context and time pressure on frontline decisions.
insights INSIGHT
Unfair Causation
"Cause" is readily applied to frontline errors, but not to systemic issues like poor maintenance or social pressures.
This is unfair, as frontline actors have fewer options and less time, their possibilities narrowed by system design.
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In this book, Don Norman discusses how design should be centered around the user's needs, emphasizing the importance of visibility, natural relationships between controls and functions, and the intelligent use of constraints. He argues that poor design, rather than user ineptness, is often the cause of frustration with everyday objects. The book covers various aspects of design, including affordances, signifiers, and the seven stages of action, providing a comprehensive guide to creating user-friendly products.
Human error
Human error
James Reason
James Reason's "Human Error" is a seminal work in human factors and ergonomics. It explores the cognitive processes that lead to errors, distinguishing between active failures and latent conditions. Reason introduces the Swiss cheese model, illustrating how multiple layers of defense can fail, leading to accidents. The book emphasizes the importance of understanding the system's role in human error, rather than solely blaming individuals. It has significantly influenced safety management systems and accident investigation methodologies across various industries. Reason's work promotes a more systemic approach to safety, moving beyond individual blame.
On this episode of the Salience Podcast, we turn our attention to the relationship between human factors, systems, and analysis of safety incidents and accidents. As you might imagine, a company with a name like Frontline Mind is intimately involved with frontline action. The agencies and people we specialize in work in fast-paced, complex, and at times high-risk environments. Inevitably, there are near misses, incidents and accidents.
How we best learn from these is not straightforward. In fact, when we work with agencies for the first time, we find that most after-action reviews or operational or cold debriefs have made matters worse. Partly, this is because there is an unrealistic focus on events that emerge and are only visible in hindsight. This is partly because there is a strong focus on errors and what went wrong. We can see and hear this bias in a deficit-based language where there is a focus on what went wrong. Now, I'm not a fan of an exclusive focus on what went well either. The danger of overdone positivity or staying in happy, clappy land is also unhelpful and is just as much of a concern as an obsession with what went wrong. So it's this use of language and the way we can direct attention that we are going to focus on today. And to help us unpack, how we can learn from near misses, incidents and accidents without falling into a judgmental binary of good and bad.
we are joined by Dr. Steven Shorrock from Eurocontrol, where he works to support aviation throughout Europe with human factors, applied psychology and systems thinking and practice. Steven is a chartered psychologist and human factor specialist. He is editor in-chief of Hindsight Magazine and adjunct associate professor at the University of the Sunshine Coast Center for Human Factors and Sociotechnical Systems.
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