SafetyInsights.org

This study unpacked three workplace events, comparing each organisation’s investigation report to the researcher’s own evaluation from a cognitive trap (error trap) perspective.

Note: I translated this from Portuguese via Google, so there could be mistakes.

Providing context they note:

·         Criticism has emerged against “concepts that presuppose the existence of direct relationships between failures, inappropriate behaviors or human errors, and accidents in the workplace”

·         Modern constructions of accident causality tend to adopt more systemic views that go beyond the psychological aspects of the individuals involved in the event

·         They note that prior work, like that from Reason, defined an error as a “generic term that encompasses all those occasions in which a planned sequence physical or mental activities fails to achieve a desired result and when these failures cannot be attributed to chance”

·         Reason introduced the idea of both active and latent factors

·         They also observe the delineation, from this perspective, from types of ‘errors’ and ‘voluntary deviations’, which Reason referred to as violations

·         It’s said that while error refers to an individual’s cognitive processes, violations refer to “external, socially defined norms and standards”

·         They argue that violations “must also be approached as special types of errors, whose origins need to be analyzed with a view to identifying latent conditions that gave rise to them”

·         Some have criticised the notion of violations, like Dekker who argued it is a value-laden judgement [** I also dislike the term]

·         Moreover, over a large number of adverse events it’s said to be difficult to distinguish what is intentional and what isn’t [** Moreover, many workarounds are intentional, but for good reasons]

·         They talk about other conceptualisations in this space like performance variability, which centres more on the systemic and cognitive dimensions; where the work context is rather seen as dynamic and variable

·         Drawing on Reason et al., it’s noted that human performance isn’t a separate and isolated function of human psychology, but connected to the environment, which can then influence cognitive processes and the probability of omissions

·         Resultingly, Reason et al. argue that several factors increase the probability of omissions,

a) task steps or activities that carry a high information load, especially relating to immediate memory,

b) steps or objects that are out of sight or inaccurate,

c) steps triggered by weak or ambiguous signals,

d) functionally isolated steps in the previous example,

e) steps that follow the main objective of the task (e.g. once the core task is completed, steps that follow may be omitted),

f) steps that are repeated,

g) change in relation to routine,

h) steps following interruption

·         These effects may also combine in unexpected or combined ways

·         They state that “activities  that  include  more  than  one  of  them were  called  by  Reason  an  “error  trap”; this study uses the term ‘cognitive traps’

·         In practice, investigations “almost always” result in attribution of blame or responsibility to the worker for missing something

I’ve skipped the detailed descriptions of each case study.

Results

Case 1:

This involved a fatal fall from an elevator. The opening and closing of the door was manual and didn’t have a device to block elevator function if the door was open.

When leaving the elevator for the platform, a worker didn’t close the door, which collided with the platform.

Quoting the paper,  during the company’s investigation “it  was  found  that,  for  the company,  the  “cause”  of  the  accident  had  been  the omission  of  the  injured  party,  now  deceased:  “it  was  he  who he  didn’t  close  the  door”.

Case 2

This event occurred during the removal of part of a universal plate from a lathe during maintenance. During the activity a pipe from outside the lathe fell and struck the maintenance worker’s hand.

According to the company’s investigation “the  failure  to  place  the  fixing  pipe  was  the  “cause”  of  the  accident,  which  consisted  of  the  plate  falling  inside  the  lathe,  hitting  the  worker’s  hand”.

A production inspector also shouldn’t have participated in the task.

Case 3

This accident occurred while a technician was carrying out maintenance on a large milling machine. The company’s investigation noted that the accident “would  have  been  “caused  by  an  unsafe  act  carried  out  by  the  injured  party”,  which  omitted  steps  from  the prescription”.

Interpretation of cognitive traps

The authors argue that each of these investigations blamed the workers when each had cognitive traps embedded within the work.

In the first case, they say that closing the elevator door constituted a functionally isolated step from the previous steps, e.g. opening the door. Hence, closing the door doesn’t extrinsically  “warn”  that  it  must  be  closed”.

The task of closing the door was said to be “barely  visible  and  triggered  by  a  weak  signal” [* I think that’s what they were saying, it’s sometimes difficult to know given the translation].

Based on Reason’s work, the visibility and sequence of work steps are intertwined, such that the presence of the open door “in  itself,  does  not  make  visible  the next  step  –  closing  it  –,  which  depends  on  the worker  remember  that  it  does  not  close automatically”. 

Moreover, only very old elevators have this manual feature, which is a change in relation to travel routines that people normally have with elevators.

Further, the omission occurred during another task (walking) to the intended location, which based on cognitive processing demands, “tends  to  mobilize  the  worker’s  attention  towards  the  activity  he  or  she  must  perform”.

Finally, closing the door “has  no  relation  to its  main  objective,  with  greater  capacity to  capture  your  attention”.

In the second case, they list several features which favoured the omission, like the falling pipe being outside the lathe’s body and barely visible, the pipe placement had no functional relationship with the previous step.

Removing the plate was also said to have been a different practice compared to usual.

The task was associated with more than one step, whose characteristics were cognitively demanding; which they described as an embedded cognitive trap.

In the third case, they highlight that the worker was performing activities that he wasn’t familiar with; a “factor  highlighted  as  [one] of  the  most  powerful  error-provoking [conditions]”

Also the functioning of the mill during the maintenance was unexpected, which “corresponds  to  what  Dekker calls  automation surprise”. Automation surprise is where the system does something unexpected by the user.

This usually appears in the presence of many factors in the following circumstances:

a) the system acts without immediate prior user input (e.g. it functions with programmed logic),

b) the system offers little feedback about its behaviours (or provides more feedback about the way or state you are in rather than what you are trying to achieve),

c) new situations.

They also found that the step of turning off the machine wasn’t functionally connected with the previous step of activating the control of manual advance. The machine also didn’t “provide  feedback  on  unobeyed  commands.  Under  these  conditions,  only  prior  knowledge  of  the  machine’s characteristics  could  protect  the  worker”.

They also propose that in any of the three cases, interruption by a colleague or other unexpected factor, as well as excessive time pressure could have increased the chance of omission.

Conclusion

In all of the three cases, it “appears  that the  initial  approaches  of  company  professionals  refer  to  the  victims’  behaviors  to  attribute  blame  to  them”, where this was more evident in case 2 where “the  victim  “confessed”  to  the  omission”.

They argue that the lack of consideration of the contextual factors made stem, in part, from the difficulties in approaching the “human dimension of sociotechnical systems”.

They recommend that the perimeter of analysis be widened. They also argue that “in  the case  of  omissions,  approaches  focused in  the  behaviors  and/or  errors  of  workers  offer  little  or  no  contribution  in  terms  of  prevention,  since  they  tend  to  leave  the  conditions  that  give  them  untouched”.

Authors: Binder, M. C. P. (2004). Cognitive traps: the case of omission in the genesis of work-related accidents. Cadernos de Saúde Pública, 20, 1373-1378.

Study link: https://doi.org/10.1590/S0102-311X2004000500032

My site with more reviews: https://safety177496371.wordpress.com

LinkedIn post: https://www.linkedin.com/pulse/cognitive-traps-case-omissions-genesis-work-accidents-ben-hutchinson-yzkfc