The irony and agony of human error


Why we don’t really learn from our mistakes… By Larry Wilson


About the author

Larry Wilson is a pioneer in the area of Human Factors in safety. He has been a safety consultant for over 25 years and has worked on-site with hundreds of companies worldwide. He is the author of SafeStart, an advanced safety and performance awareness program, successfully implemented in more than 3,500 companies, in over 60 countries, with more than 4 million people trained. He co-authored the book “Inside Out: Rethinking Traditional Safety Management Paradigms” and authored the book “Defenseless Moments: a Different Perspective on Serious Injuries”. Larry is the moderator of the SafeConnection expert panels and an active keynote speaker at health and safety conferences around the globe.

Tt started with having to go back and capitalize Irony and Agony, as if I don’t know that the key words in a title need to be capitalized. That’s just two of the many errors made so far today. And today, even though I’m flying to Latin America, has not been a bad day, in terms of making more mistakes than normal (travel days are usually worse for me). But how many mistakes a day is normal? How many do you think you make per day? How many do you think most people make. And then, what about when it is, “one of those days…”, how many mistakes do you make then?

Well, the research says around 80. That most people make about 5 per hour or around 80 a day. That’s a lot. Luckily though, that’s just the number for most people, you know, average people. And the research also says that over 80% of us think we’re better than average. So really, unless you’re in that hopeless category of average, you probably only make about 40 or 50 a day. Only! Imagine bragging about how you are twice as good as most people because you only make 40 mistakes a day. Let’s face it, 40 is hardly zero. So, there’s a fair bit of “agony” and/or frustration when you add up the wasted time, wasted money, damaged relationships and unintentional injuries that all our mistakes have caused over the course of our lifetime.

The “Irony” is that we are supposed to learn from our mistakes. And in some cases, we do. But if we are still making 80 a day, it doesn’t seem like we are learning very much. And even if you are twice as good as the average person and you’re only making 40 a day, why is it still stuck at 40? Why isn’t it steadily going down, like it would if you were actually learning something each time, or even worse, learning it again? Especially with things like the pain from standing up and banging your head or stubbing your toe. Did we need another lesson or did we already know it would hurt. How about dropping things. How many times have you dropped your keys or your phone? Would you be willing to bet a $1000 that you’d never do it again? Most people will not take that bet. And I have asked thousands of people that exact question. However, if you change it up slightly and ask, “would you bet So, it seems we have a certain amount of confidence in terms of not making mistakes over a short term but not so much over the long term.

Why? If we believe we can do it for 24 hours, why don’t we believe we can do it for the next 24 and the next 24, and so on? Perhaps we could just start stringing 24 after 24 after 24, but in order to do that we would need to remind ourselves- every day-that there was $1000 on the line. Otherwise, I wouldn’t bet that I’d never drop my phone again and probably, neither would you. $1000 that you would not drop your keys or your
phone for the next 24 hours, now almost everyone will take that bet.

The irony and agony Of human error
So, it seems we have a certain amount of confidence in terms of not making mistakes over a short term but not so much over the long term. Why? If we believe we can do it for 24 hours, why don’t we believe we can do it for the next 24 and the next 24, and so on? Perhaps we could just start stringing 24 after 24 after 24, but in order to do that we would need to remind ourselves- every day-that there was $1000 on the line. Otherwise, I wouldn’t bet that I’d never drop my phone again and probably, neither would you.

We know that somehow, we would need to continually refocus or eventually, we will make a mistake, or to carry the example forward: drop our phones or our keys. Which is where it gets really ironic, because that’s what most of us tell ourselves when we do drop our phone or make a similar but a very common mistake: we tell ourselves that we need to pay more attention, to focus, to concentrate on what we’re doing, etc. So, if the reason you dropped your phone was because of a lack of attention or focus, can you see the irony in analyzing the mistake and concluding that you’ll “just have to pay more attention in the future”? But there is some good news. There are now options or solutions with mobile technology that can help us in terms of “Anticipating Error”, that can remind us to think about the next 24 hours, and when we will likely be rushing, frustrated, tired or complacent, so we will be much less likely to make a mistake or a serious mistake that is caused by one or more of the four states.

However, there are problems, more common problems with the analysis of human error than just deluding yourself into thinking that somehow you will be able to pay more attention next time, and the next and the next and the next, without using technology or something else to remind yourself or to refocus. Another problem is that for most people there is little thought given to the “cause” compared to the amount of thought given to the “consequence” and whether or not there was a lot of luck or bad luck involved. Hence the expression: Did it fall butter-side down? Case in point: On a recent business trip to Europe, my associate and I were thinking of getting T-shirts made that said, “The 50/50 Kings” because we had lost 4 out of 5 in less than 3 days. There were only two trains. We had a 50/50 chance of getting on the right train-blindfolded. But we didn’t. On the next day, we had a 50/50 chance to get out at the second last stop not the last. We stayed on, when we should have gotten off. And then another one and then another and another. We couldn’t believe our bad luck. And that’s what we tended to focus on. And that’s when I realized how many 50/50’s there are in this life. And if all you do is think about whether you’re lucky or not, it’s impossible to learn anything that’s going to prevent the next one, unless somehow, contemplating how lucky you are actually changes how lucky you really are, which is not a good bet. A much better strategy, that I started using after the train mishaps, was to spend a lot more time thinking about the states that caused the error and, in this case, not to relax or become complacent when you get on the train until you know exactly which stop. Instead of thinking that it’s at least another 20 minutes, so I can close my eyes for a few minutes. In other words, focus on the rushing, frustration, fatigue and complacency that caused the error, instead of whether or not you’re the unluckiest person on the planet.

Ok, so much for the 50/50’s. But what about when it was more like 80/20 or 90/10. Now you’re going to feel really unlucky. How likely are you now to focus on the states or human factors that caused the error? Or are you more likely to think that now you are-definitely-the unluckiest person on the planet? Which then begs the question, “So when do we analyze any of our errors for the real causes? Answer: not very often when it’s a common mistake we’ve made 100’s or 1000’s of times like losing our balance or dropping something. And not much when it’s a 50/50. And probably even less when the odds were less or worse than 50/50. So, when do you or I or for that matter-anybody-when do we analyze our mistakes for the cause or causes? Perhaps it might be easier to give this question some numerical perspective: how many times out of 10 do you stop to analyze or think about why you made i a common or simple mistake? Note: saying, “Ouch, that really hurt”, does not qualify as analysis.

The next thing that interferes with analysis or even stopping to think for a second, is more serious, but in reality – very comical as well. So, let me start with a question: Have you noticed that the quality and substance of your excuses has improved dramatically since you were a little kid? This is because only the excuses that worked survived. You might have told your school teacher that the Martians stole your homework, but since that didn’t work you changed it to something else. And over the years, in your efforts to cover your tracks, you, me, we all got better with the excuses.

And here’s the rub: if the excuse worked and we got off “Scot free”, now… how likely is it that we’ll be thinking about rushing, frustration, fatigue and complacency or more likely, a combination of those states that lead to the error? Consider getting pulled over for speeding-even if it wasn’t deliberate and all that happened was you didn’t see the speed limit sign change. Would you be analyzing the states that lead to the error? Or would you be much more likely to be analyzing what you told the police and whether you got a ticket or just a warning? If what you said worked, then you’ll use that one again. If it didn’t, you won’t. But it’s not nearly as likely you’ll be thinking about complacency leading to the mind and eyes not on task and that’s why you didn’t see the speed limit signs change. So, we got better with diminishing and deflecting our mistakes over time, instead of analyzing the mistake and improving over time.

And finally, there’s another problem which might very well be the worst of them all. Common mistakes like dropping your keys or your phone, losing your balance, bumping into something, stubbing your toe, etc. are common. They aren’t new or different. Something like dropping your keys isn’t important unless you were standing over a grate and they fell down the drain/sewer. They aren’t interesting and they aren’t pleasurable. This means, as far as our subconscious or Reticular Activating System (RAS) is concerned, that these mistakes are just, “business as usual” or considered “normal” or “nothing out of the ordinary”, which means that we won’t hear any “alarm bells” ringing when we make one of these types of mistakes. So, the only way you will likely even notice the mistake, is if you make a conscious effort to start paying attention to all the mistakes you make. And then, get into the mental habit of analyzing the error for states or combinations of states. It won’t just happen naturally. Unfortunately, only the big mistakes will “register” or catch your attention.

If it’s a mistake, like losing your balance, traction or grip when someone is working at heights, then we can give them a fall arrest harness. If they make a mistake with eyes not on task and they don’t see the red light we can give them a seatbelt and airbags. But none of those things prevent the error in the first place. They just reduce the negative consequences. It’s like when the excuse worked. It didn’t prevent the error. It just lessened the consequences. Which is where most people are with all this. We don’t learn anything or hardly anything from the little mistakes, and quite often we focus on doing something else to lessen the consequences of the big ones-which is good and very important-but it won’t prevent the next one.

Imagine if you did learn something, even if it was only a little bit, from each mistake you made? How many would you make per day? Probably not 80, or even 40. Probably a lot less. But what you would also realize is that very few of the mistakes you make are because you are learning something new. That’s because most of us are doing things we know how to do well over 90 or 95% of the time. Making mistakes is part of the learning process. But once you have learned how to do something wellyou, me and everybody else-still makes mistakes. And with rare exceptions (caused by extreme joy or extreme sorrow), every one of those mistakes were caused by rushing, frustration, fatigue and complacency or a combination of those states. If you’re in doubt or somewhat skeptical, just ask yourself if you can think of even one mistake you’ve made when you knew what you were doing (you weren’t learning or doing something new) that wasn’t caused by rushing, frustration, fatigue and complacency or a combination of those states. And even if you can think of one example, which would be very unlikely, what about all the rest (thousands and thousands) of them?

We all know that humans make mistakes. “To err is human” is another expression that has been around for a long time. And it’s true, we all do make a lot of mistakes. But every one of them didn’t have to happen. It’s not like “what goes up must come down”, or some other universal axiom. None of the mistakes I’ve made or you’ve made had to happen. It’s not like I always get on the wrong train…We could have asked someone if we were getting on the right train. But we were complacent. We had been in a rush. We were worried about missing the train. Once we got there, with 3 minutes left to spare, we let our guard down, and just assumed the next train was ours.

So, the next time you lose a 50/50 (which will likely happen before the week is out) think about the states or combinations of states that caused the mistake. And don’t get T-shirts with the “50/50 Kings” imprinted on them unless you think it’s a good name for your new rock band.

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