David.fuller
- 1. Understanding the Perception of Risk David Fuller NASA JSC NASA PM Challenge 2010 Used with permission 9-10 February 2010 1
- 2. Organizational Accidents and Human Error It seemed like a good idea at the time David Fuller
- 3. James Reason Swiss Cheese Model LOSSES DEFENSES IN DEPTH THE IDEAL James Reason HAZARDS NASA PM Challenge 2010 9-10 February 2010 3
- 4. James Reason Swiss Cheese Model LOSSES DEFENSES IN DEPTH THE REALITY James Reason HAZARDS NASA PM Challenge 2010 9-10 February 2010 4
- 5. James Reason Swiss Cheese Model LOSSES SOME HOLES DUE TO ACTIVE FAILURES OTHER HOLES DUE TO LATENT CONDITIONS James Reason HAZARDS NASA PM Challenge 2010 9-10 February 2010 5
- 6. Human Decisions vs Human Error • Human Do Not Make Errors – Error is an artificial label applied after the fact • Humans make decisions based on their “Local Rationality” (Dekker) • Humans make decisions that may or may not have undesirable consequences • Undesirable consequences almost always occur through interaction with unconnected events NASA PM Challenge 2010 9-10 February 2010 6
- 7. Local Rationality • Humans are pattern recognition machines • We arrange new information into patterns • We superimpose the pattern onto patterns learned through experience • Not all new patterns fit with our experience – We interpolate – Sometimes we choose poorly NASA PM Challenge 2010 9-10 February 2010 7
- 8. DECISIONS DECISIONS COGNITIVE PROCESS EXPERIENCE PERCEPTION DECISIONS DECISIONS NASA PM Challenge 2010 9-10 February 2010 8
- 9. Common Cognitive Traps • Anchoring – Tendency to grab on to the first idea • Availability – Tendency to assume an easily remembered experienced explains a new situation • Attribution – Tendency to invoke stereotypes NASA PM Challenge 2010 9-10 February 2010 9
- 10. How to Avoid these Traps • Work as a team • Ask “What else could it be?” • Ask “Could it be more than one thing?” • Ask “Is there anything that doesn’t fit?” • Pay attention to your gut feelings. NASA PM Challenge 2010 9-10 February 2010 10
- 11. Experience “As a rookie I was dogged by the fact that I had only 3 seconds to get rid of the ball before I was crushed by the defense. As a 10 year veteran, I relish the fact that I have 3 seconds to get rid of the ball.”–NFL Quarterback NASA PM Challenge 2010 9-10 February 2010 11
- 12. Gaining Experience In Order of Effectiveness 1. Survive an Event 2. Personally Share an Event 3. Read About an Event Difference is the emotional content NASA PM Challenge 2010 9-10 February 2010 12
- 13. Develop Personal Situational Awareness • Understand your personal thinking process • Understand the factors that can influence decision making ability – Medications – Fatigue – Emotion – Distraction NASA PM Challenge 2010 9-10 February 2010 13
- 14. British Midlands Crash NASA PM Challenge 2010 9-10 February 2010 14
- 15. Questions? Murphy had it wrong Whatever can go wrong usually goes right, and then we draw the wrong conclusions. W. Langeweiche, 1998 NASA PM Challenge 2010 9-10 February 2010 15