In part 7, we took a critical look at the questions trainers use for diagnosis and asked whether they are the best ones to use. Now we’ll give you a brief challenge through three questions. Then later in parts 9-12 we’ll share with you a tested diagnostic process and examples of how it has been used to support human performance in a wide variety of contexts.

A challenge

Now we’ve set out the problems and some of the causes, the next step will be to look at the solutions, alternatives which may not be meant to replace training, but to form part of a mix, a cocktail of solutions that go beyond mere knowledge and skills to locate training within a performance improvement strategy that is guaranteed to bring improvement.

We are humans, and humans make errors, but the right combination of support can result in right first time on many more occasions than training alone can accomplish.

In the remaining parts of this series I’ll share with you a simple but powerful antidote to human error that ought to be in the war chest of every trainer.

In the meantime, I have three questions to intrigue you and set you thinking – I’ll give you some answers in part 9.

Question 1

If you had to rely on just one of these to protect you against terrorist attack at an airport, which one would you choose?

a) The training of security personnel

b) Sniffer dogs

c) Honey bees

Question 2

Suppose you need radical surgery to your hip. Which of these two would be more likely to result in a comfortable process with a successful outcome?

a) A robot

b) A surgeon

Question 3

This questions deals with a performance issue that’s close to my heart, since I’ve needed to give blood on three occasions in the recent past because the first sample was incorrectly gathered by a trained, competent and qualified phlebotomist.

Sally collects blood samples. Many patients are having to return for re-test.

What should be done?

Would you be sending her for more training and more qualifications, or would you adopt the approach of a human performance engineer?

What will your solution be?

That’s the end of Part 8.

In Parts 9-12 we’ll give you our answers and solutions and share with you a tested diagnostic process and examples of how it has been used to support human performance in a wide variety of contexts

In Part 6 we considered the need for physical and mental supports, and drew lessons from the US Coast Guard and the writer Rudyard Kipling. Now we’ll think about the questions trainers use for diagnosis and whether they are the best ones to use.

Silver bullet

When the costs and consequences of non-compliance can be so high, it’s no wonder organisations pour thought, effort, time and money into training. Many see it as a silver bullet. But let’s be clear that training is a clear attempt to change the worker. It can have no direct impact on the place or character of the work. And so all of that thought, effort, time and money, and all of those Kipling questions translate into the thing that training does – in order to change the worker – training; in all its many guises, formal and informal, tutored or self-administered, at work or away, instructing, coaching, managing. Building knowledge and skills, and seeking to influence attitudes.

And still catastrophe happens. Does that prove training doesn’t work? Does it mean all of that time, effort, thought and investment is wasted?

Well my answer is no …  and yes!

Sometimes it is well spent – after all we have no measure of the incidents that didn’t happen. Training is optimised if it results in a blend of solutions rather than one or two discrete strategies. But sometimes we forget that training is only one method amongst many of engineering effective performance. It is not always the right tool for the job. As trainers we are not accustomed to thinking about changing the work or the circumstances and environment in which it is done. If only we asked more questions of the right type, we might resist the belief that training must be the answer, or the only answer.

Six honest serving men

Let’s return to Kipling and take a fresh look at the six questions. What follows is not meant to be a prescriptive, nor a comprehensive list; it is a starting point, and ought to serve as a general direction in which questioning might point. Crucially it is not predicated on the assumption that training, or any other performance support must be the end result.

What?

• What seems to be a problem or needs to change?
• What conditions exist when the problem shows itself?
• What is the scale of the “problem”?
• What is the cost to the organisation?
• What is the cost to you particular stakeholders in person?
• What will be the biggest advantages of fixing it?
• What will “finish” look like?
• What will we hear people say?
• What will we see people doing in a different way?
• What happens if we leave it alone?
• What solutions have already been attempted?

Why?

• Why is it a problem?
• Why should we invest time, effort and resources in this?
• Why is this the right time to deal with it?
• Why should I get involved?
• Why has the problem not been fixed before now?

When?

• When is the problem most inconvenient?
• When is it least inconvenient?
• When do we need the change to be initiated?
• When do we need the change to be complete?

How?

• How can we get reliable, objective and scientific evidence of the current situation and its impact on our business?
• How will we prevent matters from slipping back to as they were?
• How can we win support for making a change?
• How will we know that the change has happened?
• How could the change be made apart from through Training?

Where?

• Where does the need for change appear most obvious?
• Where have we dealt with this kind of situation before?
• Where can we see the accounts of others who’ve already done what we’re considering doing?
• Where might we find a new slant on this, for example in another organisation, sector, profession or domain?

Who?

• Who is accountable for the current situation?
• Who is responsible for it?
• Who are the witting contributors?
• Who might be unwitting contributors?
• Who is most affected?
• Who stands to gain most from making the change?
• Who might block the change?
• Who might champion the change?
• Who has the capacity to supply resources, people or information that will help me to understand the situation and change it?
• Who can help us to understand better what is happening?

That is the end of Part 7. In Part 8 we’ll give you a challenge through three questions. Then later in parts 10-12 we’ll share with you a tested diagnostic process and examples of how it has been used to support human performance in a wide variety of contexts.

In Part 5 we asked why health professionals in hospitals still fail to observe simple rules of hygiene to avoid infection and cross-contamination. We profiled three behaviour patterns: skill-based behaviour, knowledge-based behaviour and rule-based behaviour. Now we’ll consider the need for physical and mental supports, see what the US Coast Guard knows, and draw lessons from Rudyard Kipling.

Physical and mental supports

And so let’s return to the notion that the right kind of intervention or support depends upon identifying what the performance blocker seems to be. If someone lacks the height, physical strength or motor co-ordination to perform a task, then no amount of training will make matters change. That’s obvious. Of course most emotional, cognitive or psychological obstacles may be less obvious than the physical mismatch between a person’s physique and the power or reach required to perform a task.

Anyone who has ever bathed a new born infant will know that a baby under these conditions may be perfectly compliant, or may be uncooperative. He will certainly be wet and slippery, and will not yet be able to sit or lie in a full sized bath without restraint. Water must be at the perfect body temperature of 37°C . Simple job aids are essential – a supportive plastic shell in which to hold the baby safe and supported; a floating thermometer that keeps a check on the temperature. Certainly there are such things as pre-natal and parenting classes, but they cannot control conditions in the physical environment at the point of performance.

What the US Coast Guard knows

Of course, early in 2012, safety at sea is tragically very topical, and there is no shortage of data related to marine, aviation, medical and environmental disasters. As the US Coast Guard notes in Prevention Through People: Quality Action Team Report (1995), when you organise people in a particular structure, mix in some technology and a hostile environment, then you have a combination of factors which affect performance. Sometimes the weak link is within the people themselves; but more often the weak link is the way that technological, environmental, or organisational elements influence the way people perform.

And when catastrophe happens, are we seeing proof that training doesn’t work? I do not mean to trivialise so much human loss and suffering, but the underlying cause of an incident like the tragic Costa Concordia is often a puzzle worthy of the great fictional detective, Sherlock Holmes.

Rudyard Kipling

Rudyard Kipling is much quoted by l&d professionals. Author of The Jungle Book and Just So Stories, and of the poem If, he also gave to trainers the gift of his six honest serving men. You know the one …

I keep six honest serving-men, (they taught me all I knew), their names are What and Why and When, and How and Where and Who.

These are good questions. Learning designers use them with great skill to arrive at the best possible training solutions:

• Who is involved?
• How many people need training?
• What do they need to know?
• Why do they need training?
• When must training start and when must it be completed?
• Where will training take place?
• How much is in the budget?
• Etc.

But do we ask them at the right time, and are there some other, better questions we should be asking too? I’ll return to this question shortly.

That is the end of Part 6. In Part 7 we’ll challenge the perception of training as a “silver bullet” and we’ll see why Kiplings’ six honest serving men deserves to be far more than a cliché for trainers.

In Part 4 we gave a little thought to the matter of memory. Now we’ll ask why health professionals in hospitals still fail to observe simple rules of hygiene to avoid infection and cross-contamination. We’ll look at performance in hospitals in Britain and the USA. We’ll begin with a profile of three behaviour patterns: skill-based behaviour, knowledge-based behaviour and rule-based behaviour.

Behaviour patterns

Skill-based behaviour

Formal published research often refers to particular behaviour patterns. One such is skill-based behaviour. This is inadequate performance due to our brains storing instructions. We don’t stop to consider how to tie a tie or shoelaces, for example; we are pre-programmed to do it. We become so familiar with aspects of our daily work routines that they become second nature. That’s fine as long as nothing changes, but when we become this comfortable with our environment, we open ourselves up to errors from overconfidence— the “I’ve done this a thousand times” mentality.

Knowledge-based behaviour

This is inadequate human performance governed by analytical processes and stored knowledge. It occurs when we face a situation that we have never faced before (or infrequently faced) and no stored rules exist for it that would provide us guidance. In such cases, we must depend on our knowledge and expertise to solve the situation. For example, much of the chaos associated with the first responders’ response to the 9/11 attacks was due to the fact that their disaster preparedness plans did not anticipate that type of attack. Therefore, first responders had to rely on their individual experience and expertise in how to effectively respond.

Rule-based behaviour

This is inadequate human performance governed by stored rules accumulated via experience and training. For example, we are typically governed by policies and procedures within our work environments. Some hospital workers are lax about hand-washing hygiene because they have never personally suffered an infection and so feel the risk is overstated. In other circumstances, for example in the case of CPR, campaigns recognise that some people are reluctant to do it because they don’t believe they can or because they would “feel stupid” doing it in public. Like the Massachusetts cartoons on delaing with strokes, the British Heart Foundation video It’s Not Hard  featuring Vinnie Jones makes use of all the appropriate media – and a good deal of humour.

Example

Matters might have improved a little over the past 5 years but unwashed hands in the UK’s hospitals still contribute to the spread of MRSA. Ensuring health professionals follow simple rules of hygiene like hand washing is key to stopping bacteria spreading. But observed practice shows very poor rates of adherence to guidelines and reveals that staff fail to take account of risk, even with patients with MRSA. The Journal of Hospital Infection reported that 38 per cent of a research sample of health professionals failed to wash their hands after contact with MRSA patients, while 25 per cent failed to wash their hands after contact with faeces and 38 per cent failed to wash their hands after contact with blood. This was despite the knowledge that they were being observed. The Professor of Psychology heading the research said, ‘What is most worrying here is that healthcare professionals say one thing and they do another. There is no link between what they say and what they do. If we adopt a culture where we urge healthcare workers to treat everyone as if they are infected, then they stop risk assessing. They can’t wash their hands all the time, so we need to teach them how to risk assess.” 2006 research from the University of Hertfordshire and the Institute for Employment Studies (IES)

Figures from a spot check in South Wales showed that 42 per cent of doctors and consultants were failing to clean their hands properly according to guidelines. When challenged over whether they had washed their hands, some asked “why?” A director of nursing said: “We have had a lot of discussions at executive board. We instigate disciplinary action if they have been told to wash their hands and they don’t do it again.” The culture of not washing hands was affirmed to be completely unacceptable, and yet it was still, “a custom more honour’d in the breach than the observance” (Shakespeare, Hamlet).

The North Carolina approach

The same problem exists further afield, in North Carolina, where years of awareness programs have had little effect. Part of the problem, according to a study in the journal Psychological Science, are the actual signs posted in hospital washrooms urging health care workers to wash up. Changing the message from “Wash Your Hands to Protect Yourself” to “Wash Your Hands to Protect Your Patients,” the study found, could motivate some doctors and nurses to wash their hands more frequently. The patient-focused sign produced a 33 percent increase in the amount of soap and disinfectant used per dispenser over a two-week period, compared with the other signs. In a second phase of the study, trained observers recorded how often doctors and nurses physically washed or disinfected their hands. The sign urging doctors to think about patients produced a roughly 10 percent spike in hand washing compliance, a jump that was small but statistically significant.

That is the end of Part 5. In Part 6 we’ll consider the need for physical and mental supports, see what the US Coast Guard knows, and draw lessons from Rudyard Kipling.

In Part 3 we took 24 explanations of human error and asked, “Do you think this can be resolved through training alone?” Now we’ll give a little thought to the matter of memory.

Memory

Trainers love to quote the Ebbinghaus curve and the limitations of memory. Lapses of memory go unnoticed, when the consequences are slight. Even so trainers often use mnemonics and other types of memory aid. They can be fun and easy to devise. They are a classic example of a performance aid – a strategy to support and sustain required levels of human performance. Much use is made of video combined with music, rhythm and rhyme. A very good contrast can be seen between two approaches to raising awareness of how to deal with stroke victims using the acronym FAST. The UK Department of Health spent £12m on advertising and publicity designed to raise awareness of stroke among healthcare professionals and the general public. A video forms part of the materials and can be seen at Recognise Stroke F.A.S.T.

In the British video there is very high fidelity – a woman is shown having a stroke. A fire is burning in her brain. The images are very disturbing and, in my experience, take away attention from the core objective which is to embed the acronym FAST in my memory. Instead I remember the horror of the images and resolve to look away the next time I see it. In the USA, different approaches are used. In the Massachusetts Department of Health multi-lingual video Stroke Heroes Act Fast, much use is made of music, rhythm, rhyme and repetition – in the mode of one of history’s most successful intervention programmes, Sesame Street. After two viewings I found myself humming the catchy tune with the words of the rhyme firmly fixed in my mind:

Does her face seem a little bit uneven?

Does one arm drift down?

Is her speech coming out kind of strangely?

It’s time, time to call nine-one-one.

Most important – I found I had internalised the acronym F=Face, A=Arms, S=Speech and T=Time (to call for an ambulance). The National Stroke Association of America takes a similar approach, which is less appealing to me personally, but may well work best for the younger audience at whom it is aimed. It features a rap by Hip Hop star Doug E Fresh and a dance called “doin’ the stroke” under the title Stroke ain’t no Joke!

That is the end of Part 4. In Part 5 we’ll ask why health professionals in hospitals still fail to observe simple rules of hygiene to avoid infection and cross-contamination. We’ll look at performance in hospitals in Britain and the USA and we’ll profile three behaviour patterns: skill-based behaviour, knowledge-based behaviour and rule-based behaviour.

In part 2 we questioned why people do not get things right first time, every time, and examined 6 prime factors that prevent them from performing to the necessary standard. Now we’re going to see how human error is explained by humans.

Human error as explained by humans

We don’t get things right first time every time because we are human beings, and prone to error.

If we look more closely at the human behaviours that result in errors, we can try to further classify them. We might conclude that certain types of behaviour result in certain types of error. Then we can take the most effective counter-measures to make those errors less frequent or less damaging.

If we could listen in to the things people typically say when things have gone wrong, we’d get a strong clue as to the type of behaviour we might be dealing with. Here are 2 dozen “explanations” we’ve come across. As you read them, ask yourself of each one, “Can it be rectified through training alone?”

Do you think this can be resolved through training alone?
	Yes	No
1)      There’s never been a problem in the past
2)      If I had to put that amount of care and effort into it every time…
3)      We always used to…
4)      I’ve not done it very much
5)      So I went and…
6)      I just didn’t notice…
7)      That’s not how I was taught…
I forgot
9)      They gave me the wrong information
10)   I’ve never been any good with numbers
11)   I only looked away for a moment or two
12)   I’ve never done it that way before
13)   It was too heavy
14)   I thought…
15)   Something got in my way
16)   It was too big
17)   It was too fast
18)   But it’s never caused any problems in the past
19)   I’ve always done it this way
20)   There were just too many of them
21)   Who could have predicted that?
22)   It just didn’t feel right
23)   I’ve always been OK up to now
24)   What’s the likelihood of that ever happening to me?

One reason for mistakes is when sticking to the familiar plan results in an unintended outcome. Either the original plan was wrong, or it was followed in the wrong circumstances. For example, a pharmaceutical manufacturer buys a new Alpine Mill with which to grind materials to powder. An operator is off sick when the training is done. She returns to work and operates the system using an old start-up procedure that she learned on a previous system. As a result, a batch of drugs is contaminated and a whole shift is lost followed by time spent in stripping, cleaning and restoring the machinery.

That is the end of Part 3. In Part 4 we’ll look at some contrasting aids to memory.

In the first part of this series we listed some well-known and tragic cases of under-performance, and asked, “If the people were trained, how could things go so badly wrong?” Here we’ll investigate why people do not get things right first time, every time, and we’ll examine 6 prime factors that prevent people from performing to the necessary standard.

Why don’t people get things right first time, every time?

There are 6 common reasons why performance deficit might occur.

1) Task perception.

People follow the wrong instructions, or fail to realise their personal responsibility for an outcome. They misinterpret what has to be done and, for example, cut short safety procedures in order to save time or money.

2) Capability and experience

Lack of appropriate training or skills will surely inhibit a person’s ability to perform a task. Failure to follow instructions, a lack of appreciation of the consequences of their actions, choosing to follow an inappropriate procedure and jumping to conclusions about the nature of a situation are all symptoms of lack of experience.

3) The work environment is often at the core of performance issues

Information overload makes it difficult to identify important pieces of information and easier to ignore or delay scrutiny. Task overload impairs the ability to monitor developments and to formulate reactive or pro-active responses. An unsuitable work environment, equipment, or procedures increases the chance of mistakes.

4) People make mistakes

People slip up for reasons that are sometimes more easily explainable than at others. Slips may happen predictably or at random. People fail to detect unusual or uncommon situations. They wrongly assess a situation, or take a determined stance due to complacency, or over-confidence because a task is so familiar and regular for them.

5) Motivation

An incentive may not guarantee a high level of performance, but a disincentive is sure to hinder. Without a positive consequence there is a high probability of failure due to lack of concentration, the absence of a sense of personal ownership of a problem, low accountability and personal objectives taking priority.

6) Actions of others

It’s easy to blame others, but when you look at enquiries into marine, environmental and aviation disasters, failure to communicate information is frequently high on the list of causes. People relate how their responses were frustrated by the actions of others who supplied incorrect or faulty components or made an inadequate quality of contribution.

That is the end of Part 2. In Part 3 we’ll see how human error is explained by humans. There will be 24 explanations and for each we’ll ask you, “Do you think this can be resolved through training alone?

This series has 12 parts. First we’ll consider some well-known and tragic cases of under-performance, and we’ll pose the question, “If the people were trained, how could things go so badly wrong?” Then in Part 2 we’ll investigate why people do not get things right first time, every time, and we’ll examine six prime factors that prevent people from performing to the necessary standard.

Part 3 is about how human error is explained by humans and Part 4 deals with memory.

In Part 5 we’ll reveal some lessons to be learned from research into hand-washing behaviour in hospitals and in Part 6 we’ll look at physical and mental supports, what the US Coast Guard can teach us and a lesson from Rudyard Kipling. Part 7 is about the view of training as a silver bullet, then we set you a challenge in Part 8 and the three remaining parts describe an ingenious diagnostic process, with examples of how many varieties of job aid have been used to support human performance in a wide variety of contexts. We hope you will find the article and the mobile app that we’ll publish with the final part to be thought provoking and of practical use to trainers, training designers and consultants.

The factory of the future

There is a 20th century joke that I’ve often quoted down the years. It goes like this: the factory of the future will be staffed by one man and one dog. The man is there to feed the dog. The dog is there to make sure the idiot does not interfere with the machinery

Now I have always had the uncomfortable sense that this is rather more of an authentic prediction than a joke, but one thing is certain – a man is a human being, and humans make mistakes.

I’ve been involved in education and training since 1972, and that’s not counting my own schooldays. Thanks to the influence of two great men, Peter Pipe and my very dear friend Mike Sleight, I have been inspired by the concept of human performance technology for a large part of those 100 years! Contemporary writers and thinkers such as Dr. Allison Rossett, long time Professor of Educational Technology at San Diego State University and other members of ISPI (International Society for Performance Improvement) have kept the flame burning, but the torch seems to flicker only dimly on this side of The Atlantic. So in this series my theme is performance aids, and I hope to demonstrate how they support anyone who has to supervise, manage or perform a task to meet a business or personal objective. I regard them as a rich but under-exploited seam; one that is systemically overlooked by trainers and instructional designers.

Dateline of disasters

Please excuse a little melodrama, but I’d like you to read this dateline of disasters:

• 1957 Windscale, Cumbria
• 1967 Cornwall, The Torrey Canyon
• 1979 3 Mile Island, Pennsylvania
• 1979 Woolworths Store, Manchester
• 1986 Chernobyl
• 1989 Hillsborough, Sheffield
• 1999 Ladbroke Grove, London
• 2005 Athens 2005, Flight 522
• 2010 Gulf of Mexico
• 2011 Fukushima Daiichi
• 2012 Italy off the coast of Tuscany, The Costa Concordia

Let’s look in more detail at just one of those. An enquiry reached the conclusion that a series of human errors caused the Cypriot Helios Airways Boeing 737-300 to crash near Athens in August 2005, killing all 121 persons on board. The flight from Larnaca to Prague had flown on autopilot for nearly two hours before running out of fuel and slamming into a hillside. The report said the pilots misread instruments regulating cabin pressure and misinterpreted a warning signal. Maintenance officials on the ground were also blamed for leaving pressure controls on an incorrect setting.

In addition, the plane’s manufacturers Boeing took “ineffective” measures in response to previous pressurisation incidents in the particular type of aircraft, the Greek report said. The plane was starved of oxygen as it gained altitude, which rendered the pilots and passengers unconscious.

Two Greek air force fighter jets were scrambled when the aircraft lost radio contact. Their flight crew saw the Boeing’s pilots slumped over the controls and a flight attendant struggling to control the aircraft before it crashed.

Were the people trained?

So what can we deduce from this and the other examples in my dateline of disasters, above?

Here a bad judgement, there some confusion over a stuck valve. A misread instrument, a warning signal ignored. A pressure gauge set to the wrong value. Thousands of deaths. Massive environmental damage. Huge loss of trust and reputation. Massive loss of revenue.

And the inevitable question surfaces – were those people trained? Those oil and nuclear workers – were they trained? Was the train driver trained? The store staff, the police and stadium stewards, the ground staff, the pilots, the captain and crew. Were they trained?

And back comes the answer with unerring reliablity – yes, yes, yes and yes. All were trained, competent, qualified, and in many cases experienced too. So what went wrong? What led trained, qualified and competent people fail to perform as necessary at the very moment when their knowledge and skills were most needed?

In Part 2 we’ll investigate why people do not get things right first time, every time, and we’ll examine six prime factors that prevent people from performing to the necessary standard.