Archives For Psychology

Human psychology and the role it plays in decision making under uncertainty.

Deepwater horizon (Image source NY Times)

Mindfulness and paying attention to the wrong things

As I talked about in a previous post on the Deepwater Horizon disaster, I believe one of the underlying reasons, perhaps the reason, for Deepwater’s problems escalating to into a catastrophe was the attentional blindness of management to the indicators of problems on the rig, and that this blindness was due in large part to a corporate focus on individual worker injury rates at the expense of thinking about those rare but catastrophic risks that James Reason calls organisational accidents. And, in a coincidence to end all coincidences there was actually a high level management team visiting just prior to the disaster to congratulate the crew as to their seven years of injury free operations.

So it was kind of interesting to read in James Reason’s latest work ‘A Life in Error‘ his conclusion that the road to epic organisational accidents, is paved with declining or low Lost Time Injury Frequency Rates (LTIFR). He goes on to give the following examples in support:

  • Westray mining disaster (1992), Canada. 26 miners died, but the company had received an award for reducing the LTIFR,
  • Moura mining disaster (1994), Queensland. 11 miners died. The company had halved its LTIFR in the four years preceding the accident.
  • Longford gas plant explosion (1998), Victoria. Two died, eight injured. Safety was directed to reducing LTIFR rather than identifying and fixing the major hazards of un-repaired equipment.
  • Texas City explosion (2005), Texas. The Independent Safety Review panel identified that BP relied on injury rates to evaluate safety performance.

As Reason concludes, the causes of accidents that result in a direct (and individual injury) are very different to those that result in what he calls an organisational accident, that is one that is both rare and truly catastrophic. Therefore data gathered on LTIFR tells you nothing about the likelihood of such a catastrophic event, and as it turns out can be quite misleading. My belief is that not only is such data misleading, it’s salience actively channelises management attention, thereby ensuring the organisation is effectively unable to see the indications of impending disaster.

So if you see an organisation whose operations can go catastrophically wrong, but all you hear from management is proud pronouncements as to how they’re reducing their loss time injury rate then you might want to consider maintaining a safe, perhaps very safe, distance.

Reason’s A Life in Error is an excellent read by the way, I give if four omitted critical procedural steps out of five. :)

One of the trophes I’ve noticed in design projects over the years is the tendency of engineers to instinctively jump from need to a singular conceptual solution. Unfortunately that initial solution rarely stands the test of time, and inevitably at some crisis point there’s a recognition that this will not work and the engineers go back to change the concept, often junking it completely.

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How do we  give meaning to experience in the midst of crisis?

Instead people strive to create a view of it by establishing a common framework into which events can be fitted to makes sense of the world, what Weick (1993) calls a process of sensemaking. And what is true for individuals is also true for the organisations they make up. In return people also use an organisation to make sense of what’s going on, especially in situations of uncertainty, ambiguity or contradiction.

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Silver Blaze (Image source: Strand magazine)

Gregory (Scotland Yard detective): “Is there any other point to which you would wish to draw my attention?”
Holmes: “To the curious incident of the dog in the night-time.”
Gregory: “The dog did nothing in the night-time.”
Holmes: “That was the curious incident.”

What you pay attention to dictates what you’ll miss

The point that the great detective was making was that the absence of something was the evidence which the Scotland Yard detective had overlooked. Holmes of course using imagination and intuition did identify that this was in fact the vital clue. Such a plot device works marvelously well because almost all of us, like detective Gregory, fail to recognise that such an absence is actually ‘there’ in a sense, let alone that it’s important.

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John Adams has an interesting take on the bureaucratic approach to risk management in his post reducing zero risk.

The problem is that each decision to further reduce an already acceptably low risk is always defended as being ‘cheap’, but when you add up the increments it’s the death of a thousand cuts, because no one ever considers the aggregated opportunity cost of course.

This remorseless slide of our public and private institutions into a hysteria of risk aversion seems to me to be be due to an inherent societal psychosis that nations sharing the english common law tradition are prone to. At best we end up with pointless safety theatre, at worst we end up bankrupting our culture.

I guess we’re all aware of the wave of texting while driving legislation, as well as recent moves in a number of jurisdictions to make the penalties more draconian. And it seems like a reasonable supposition that such legislation would reduce the incidence of accidents doesn’t it?

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The igloo of uncertainty (Image source: UNEP 2010)

Ethics, uncertainty and decision making

The name of the model made me smile, but this article The Ethics of Uncertainty by TannertElvers and Jandrig argues that where uncertainty exists research should be considered as part of an ethical approach to managing risk.

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Fraud and framing

21/10/2013 — 1 Comment

In a slight segue, I was reading Bruce Schneier’s blog on security and came across this post on the psychology behind fraud. Bruce points to this post on why, yes I know, ‘good people do bad things’. The explanation that researchers such as Ann Tenbrunsel of Notre Dame offer is that in the same way that we are boundedly rational in other aspects of decision making so to are our ethical decisions.

In particular, the way in which decision problems were framed seems to have a great impact upon how we make decisions. Basically if a problem was framed without an ethical dimension then decision makers were much less likely to consider that aspect.

Additionally to framing effects, researchers found in studying collusion in fraud cases most people seem to act from an honest desire simply to help others, regardless of any attendant ethical issues.

What fascinates me is how closely such research parallels the work in system safer and human error. Clearly if management works within a frame based upon performance and efficiency, they are simply going to overlook the down side completely, and in a desire to be helpful why everyone else ‘goes along for the ride’.

There is as I see it a concrete recommendation that come out of this research that we can apply to safety; that fundamentally safety management systems need to be designed to take account of of our weaknesses as boundedly rational actors.

One of the perennial issues in regulating the safety of technological systems is how prescriptively one should write the regulations. At one end of the spectrum is a rule based approach, where very specific norms are imposed and at least in theory there is little ambiguity in either their interpretation or application. At the other end you have performance standards, which are much more open-ended, allowing a regulator to make circumstance specific determinations as to whether the standard has been met. Continue Reading…

Taboo transactions and the safety dilemma Again my thanks goes to Ross Anderson over on the Light Blue Touchpaper blog for the reference, this time to a paper by Alan Fiske  an anthropologist and Philip Tetlock a social psychologist, on what they terms taboo transactions. What they point out is that there are domains of sharing in society which each work on different rules; communal, versus reciprocal obligations for example, or authority versus market. And within each domain we socially ‘transact’ trade-offs between equivalent social goods.

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