1. Understanding the
Perception of Risk
David Fuller
NASA JSC
NASA PM Challenge 2010
Used with permission 9-10 February 2010 1

2. Organizational Accidents
and
Human Error
It seemed like a good idea at the time
David Fuller

3. James Reason
Swiss Cheese Model
LOSSES
DEFENSES
IN DEPTH
THE
IDEAL
James Reason
HAZARDS
NASA PM Challenge 2010
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4. James Reason
Swiss Cheese Model
LOSSES
DEFENSES
IN DEPTH
THE
REALITY
James Reason
HAZARDS
NASA PM Challenge 2010
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5. James Reason
Swiss Cheese Model
LOSSES
SOME HOLES DUE
TO ACTIVE
FAILURES
OTHER HOLES
DUE TO LATENT
CONDITIONS
James Reason
HAZARDS
NASA PM Challenge 2010
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6. Human Decisions vs Human Error
• Human Do Not Make Errors
– Error is an artificial label applied after the fact
• Humans make decisions based on their “Local
Rationality” (Dekker)
• Humans make decisions that may or may not
have undesirable consequences
• Undesirable consequences almost always occur
through interaction with unconnected events
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7. Local Rationality
• Humans are pattern recognition machines
• We arrange new information into patterns
• We superimpose the pattern onto patterns
learned through experience
• Not all new patterns fit with our experience
– We interpolate
– Sometimes we choose poorly
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8. DECISIONS DECISIONS
COGNITIVE
PROCESS
EXPERIENCE PERCEPTION
DECISIONS DECISIONS
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9. Common Cognitive Traps
• Anchoring
– Tendency to grab on to the first idea
• Availability
– Tendency to assume an easily remembered
experienced explains a new situation
• Attribution
– Tendency to invoke stereotypes
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10. How to Avoid these Traps
• Work as a team
• Ask “What else could it be?”
• Ask “Could it be more than one thing?”
• Ask “Is there anything that doesn’t fit?”
• Pay attention to your gut feelings.
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11. Experience
“As a rookie I was dogged by the fact that I had
only 3 seconds to get rid of the ball before I was
crushed by the defense. As a 10 year veteran, I
relish the fact that I have 3 seconds to get rid of
the ball.”–NFL Quarterback
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12. Gaining Experience
In Order of Effectiveness
1. Survive an Event
2. Personally Share an Event
3. Read About an Event
Difference is the emotional content
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13. Develop Personal Situational Awareness
• Understand your personal thinking
process
• Understand the factors that can influence
decision making ability
– Medications
– Fatigue
– Emotion
– Distraction
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14. British Midlands Crash
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15. Questions?
Murphy had it wrong
Whatever can go wrong usually goes right,
and then we draw the wrong conclusions.
W. Langeweiche, 1998
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