Oops, I didn’t mean to do that – Why we make mistakes
Fassinating artickle by Rob Sams (see his previus posts here). The first 3 people to email me and tell me why I chose this image for this article will win a free copy of Dr Rob Long’s latest book REAL RISK – Human Discerning and Risk
I was recently staying in a hotel room with my partner where the bathroom was pretty small. We had our stuff everywhere! It came time to brush my teeth and thankfully my partner came into the room just as I was putting what I thought was toothpaste on my brush….. It wasn’t. I was just about to brush my teeth with her hand cream! I’d made a mistake, it wasn’t life threatening, and I laugh at it now, but how could I make such a mistake?
I’ve brushed my teeth thousands of times, in fact I couldn’t tell you the number of times that I’ve put toothpaste on a tooth brush, and every other time I have done so without making a mistake. Why did I nearly get it wrong this time?
It can be frustrating when mistakes are made. If we make mistakes ourselves, we are often left thinking “why did I do that” or “I hadn’t noticed that before”. When others make mistakes, particularly in the context of safety and work, we can become easily frustrated and think “but I’ve told them a number of times how to do that” or “they’ve been trained, why don’t they just do what they’ve been trained do to”.
The truth, and reality is, that we all make mistakes. We do things that we don’t mean to do because of systemic biases in the way we see, remember and perceive the world around us.
Hallinan (2009), in his book Why We Make Mistakes (Link to Book on Amazon) explores this topic and looks at; how we look without seeing, forget things in a second and are all pretty sure we are way above average. Hallinan notes that we are all biased, we just don’t know we are. These biases can be very helpful in the way we go about our daily life. As Hallinan (p. 3) notes, we are very quick to size up a situation. Within a tenth of a second after looking at a scene, we are usually able to extract its meaning. The price we pay though for this rapid review is that we often miss a lot of details. As Hallinan (p. 4) notes “where the problem comes in is that we don’t think we’ve missed anything, we think we’ve seen it all”.
A classic case in the safety and risk industry where this bias comes into play is when conducting incident investigations. Hallinan (p. 5) again, provides some useful thought on this when he says “investigators who are presumed to be impartial. But they are plagued by a bias of their own; they know what happened. And knowing what happened alters our perception of why it happened.” We call this hindsight bias and this often leads to us overlooking details and things that we ought to have seen, another mistake we can all make.
There are many reasons why we make mistakes and in my career in safety and risk I have heard a lot of commentary on this. I often hear views from people about others who make mistakes, such as:
· not being intelligent,
· not being able to listen,
· not following instructions
· not following training and even;
· people not caring about their own safety
All of these comments, and there are many more, are not helpful in generating understanding. What is more useful is understanding and considering Hallinan’s work. He provides a much better perspective on why people make mistakes, some of which I’ve outlined below:
- Overconfidence – or as we call it in social psychology, ‘hubris’. When we perform a task or a job over and over, we can become very good at it. When we do a job well for a long time, it stands to reason that we become confident in doing that task. When we get this feeling, we may think things like “all’s good here, nothing could go wrong with this job” and “I’ve done this job so many times before, what could go wrong?”. When you are observing and listening well in the workplace, you should be looking out and listening for signs of overconfidence. Where you hear, or observe people showing signs of overconfidence, your response is important. One option is to interject immediately and tell the person what you’ve seen, but this approach may not help the person to learn, they may just follow your instruction. Another, and certainly a much more effective option, is to engage in a conversation with that person and start by asking an open question. In this conversation you should aim for the person to recognise their own over confidence. This approach is far more likely to lead to the person learning more about this (rather you just telling them) and therefore mean they are less likely to do this again. For some further reading on the art of ‘asking’ instead of ‘telling’, see the attached great piece from my colleague Gabrielle Carlton (Gabrielle Carlton – Humble Enquiry)
- Our Seeing isn’t always effective – we only see a fraction of what we think we see (indeed, scientists tell us that our vision only runs at 40 bits a second). Hallinan (p. 12) notes that “the eye is not a camera. It doesn’t take pictures of events and it doesn’t see everything”. The eye moves and adjusts all the time to the environment it is in and what the eye sees depends on who is doing the seeing. Hallinan notes for example that “women tend to notice details of a woman whose purse is snatched and men notice the thief”. In safety and risk, we see examples of this all the time. When talking with people about hazards and incidents, it can be amazing the number of different ways different people see things.
- Change Blindness – that is, we notice things on a need to know basis. When we are focused on one, or a few particular tasks, we will often overlook or not see something that might be obvious to others. British social psychologist Derren Brown (http://en.wikipedia.org/wiki/Derren_Brown) conducted a classic experiment about this in central London. In his experiment, Brown shows people asking for directions to various sites in London. As the person is asking for directions, they are interrupted by a large sign that passes between the person asking, and the person receiving the directions. As the sign passes by, the person asking for the directions changes and the other person seems none the wiser. The reason that this happens, is that the person giving the directions is focused more on the map and the task at hand than the other person. The results may surprise you. You can see the experiment for yourself on the video below. Can you imagine how change blindness might play out so often when it comes to safety and risk and can you see why this might be the cause of someone making a mistake.
So we can all make mistakes. Some quite innocent like nearly brushing your teeth with hand cream, and of course others with far greater consequences. One of our constant frustrations in safety and risk can be not understanding why people make mistakes. Hopefully you will now have a better appreciation of just some of the reasons why we make mistakes. If you’d like to learn more, I can recommend you read Hallinan’s book, it has great insights on this common cause of frustration.
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