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.