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