Lapses and Loops in Human Error

I post regularly on the fantastic client experience on the Leadership for Growth programme. But as Programme Manager it is a hugely thought-provoking experience for me and always inspiring seeing the energy, ideas and progress in the sessions.

I am also constantly reminded of the value of cognitive and behavioural psychology in the workplace. Yesterday had me thinking a lot about potential deployment of cognitive countermeasures to reduce human error, especially necessary in mission critical processes and high stakes scenarios.

Beyond system or training failures, errors can usually be attributed to stress, fatigue, frustration or complacency but in many instances are due to habitual autopiloting in task completion. This is akin to?System 1 thinking - a relegation of a task to more unconscious processing; a mind wandering instigated by boredom or facilitated by expertise.? Traditional automation can promote an Out of the Loop (OOTL) performance problem, a particular type of lapse in attention.

Even high competence individuals who understand the stakes, who have been well trained and incentivised for focused performance can drift into an automatised routine that can be prone to error. Additionally, perseveration, i.e. continuing with a behavioural routine despite feedback that it is inadequate (or doing the same thing and expecting different results), can be the cause of major errors in problem solving. The solution space is narrowed into a repetitive loop. Perseveration has been studied in aviation, aerospace, driving, trading, supervision, naval maneuvers, elite sports, nuclear operations (see Dehais et al., 2019 for a review). It is linked to problems with attention shifting capabilities.

Where autopiloting involves a cognitive drift to System 1, perseveration occurs with cognitive overload of System 2 due to frustration, stress or anxiety.??

So how do you intervene when people know what they should be doing but errors persist? .Experimenting with potential solutions might help but diagnosing the cause of the human error is important as a starting point.

If the error is rooted in a lapse due to fatigue or complacency, that requires a certain approach, e.g.:

• Assessing employee fit and ability for monotonous, high volume work.?
• Introducing artificial variety or gamification to mundane monotonous tasks??
• Examining shift structure and rest periods and methods to reduce fatigue.
• Exploring means of intermittent attentional capture to refocus consciously on the task.
• Making task steps more salient and purposeful?Salience could require a multimodal instructional interface / access to live multisensory data. (behavioural cues, alarms, audio/visual reminders)

Note that the conscious focused attention (i.e. System 2 vigilance) that we would want for important tasks is effortful and difficult to sustain. Adding redundancy to work units (multiple eyes on task) may lessen the chance of errors from any individual slipping into autopilot (System 1). I think it is unlikely you could train or incentivise these errors away.

If the error is rooted in a loop due to perseveration from cognitive overload, that requires a different solution, e.g.:

• Decreasing task complexity, stress and anxiety where possible.
• Signalling instructions within the field of focus rather than trying to capture attention. Alarms/systems used to warn operators of error tend not to be perceived in perseveration as attentional shifting is impaired. Instead, leverage where they are focused to deliver live data.
• Fostering a healthy work environment and a culture with strong human connections, trust and respect can lessen the chances of mental overload.?
• Improving physical health through sleep, diet and exercise can give employees a cognitive buffer.
• Raising awareness of attention deficits in the workplace can help with organising against them.

Between the disengagement of a lapse and the overload of a loop is a sweet spot for cognitive and physiological arousal - the more than century old Yerkes-Dodson Law for optimal arousal (Hebbian version shown in cover image).?

Not every job can occupy this space so look at employee fit and trial task-based, environmental or wider cultural solutions if you want to reduce human errors. Most importantly, know which tail of the Y-D curve is contributing to errors.