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	<title>User Experience and Cognitive Engineering &#187; Human Errors</title>
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		<title>User Experience and Cognitive Engineering &#187; Human Errors</title>
		<link>http://francoisaubin.com</link>
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		<item>
		<title>Moody’s rates Moody’s&#8217; negatively.</title>
		<link>http://francoisaubin.com/2009/03/04/moody%e2%80%99s-rates-moody%e2%80%99s-negatively/</link>
		<comments>http://francoisaubin.com/2009/03/04/moody%e2%80%99s-rates-moody%e2%80%99s-negatively/#comments</comments>
		<pubDate>Thu, 05 Mar 2009 03:29:04 +0000</pubDate>
		<dc:creator>Francois Aubin</dc:creator>
				<category><![CDATA[Human Errors]]></category>
		<category><![CDATA[Human Factors]]></category>
		<category><![CDATA[Moody's]]></category>

		<guid isPermaLink="false">http://francoisaubin.com/?p=63</guid>
		<description><![CDATA[Moody’s gave the best rating to PCAA in 2007. Desjardins lost 591 million because of PCAA in the last quarter of 2008.  In 2009, Moody’s express warning on the Risk Management at Desjardins since  they do not manage properly complex financial products such as the PCAA.
It appears that overconfidence in Moody’s was one of Desjardins [...]<img alt="" border="0" src="http://stats.wordpress.com/b.gif?host=francoisaubin.com&blog=509005&post=63&subd=francoisaubin&ref=&feed=1" />]]></description>
			<content:encoded><![CDATA[<div>Moody’s gave the best rating to PCAA in 2007. Desjardins lost 591 million because of PCAA in the last quarter of 2008.  In 2009, Moody’s express warning on the Risk Management at Desjardins since  they do not manage properly complex financial products such as the PCAA.</div>
<p>It appears that overconfidence in Moody’s was one of Desjardins biggest mistake in this matter. The irony here is that Moody’s rate negatively institutions (Desjardins) that are in difficulty because they relied on Moody’s positive rating of certain financial product. It sound like Moody’s rates Moody’s&#8217; negatively.</p>
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		<title>Leading change:  the practitioner’s view</title>
		<link>http://francoisaubin.com/2008/01/03/leading-change-the-practitioner%e2%80%99s-view/</link>
		<comments>http://francoisaubin.com/2008/01/03/leading-change-the-practitioner%e2%80%99s-view/#comments</comments>
		<pubDate>Thu, 03 Jan 2008 12:30:37 +0000</pubDate>
		<dc:creator>Francois Aubin</dc:creator>
				<category><![CDATA[Change Management]]></category>
		<category><![CDATA[Christopher Wickens]]></category>
		<category><![CDATA[Cognitive Egonomics]]></category>
		<category><![CDATA[Cognitive Engineering]]></category>
		<category><![CDATA[Don Norman]]></category>
		<category><![CDATA[Human Errors]]></category>
		<category><![CDATA[Human Factors]]></category>
		<category><![CDATA[Jack Welch]]></category>
		<category><![CDATA[User Experience]]></category>
		<category><![CDATA[cognitive ergonomics]]></category>
		<category><![CDATA[cognitive group]]></category>
		<category><![CDATA[Bush approval ratings]]></category>
		<category><![CDATA[Leading Change]]></category>

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		<description><![CDATA[A few years ago, I was in a group that got lost during a hiking trip. One member of the group said &#8220;I know the way out.  We just have to turn right and walk in that direction for 10 minutes; we will see a little farmhouse and the road to civilization&#8221;.  He [...]<img alt="" border="0" src="http://stats.wordpress.com/b.gif?host=francoisaubin.com&blog=509005&post=43&subd=francoisaubin&ref=&feed=1" />]]></description>
			<content:encoded><![CDATA[<p>A few years ago, I was in a group that got lost during a hiking trip. One member of the group said &#8220;I know the way out.  We just have to turn right and walk in that direction for 10 minutes; we will see a little farmhouse and the road to civilization&#8221;.  He was sure of himself. We followed his lead but after 15 minutes of walking, no sign of the little farmhouse. The group began questioning the direction.  After a while, it became obvious that we were led in the wrong direction. This leader failed and the magnitude of his failure was greater because of the high degree of confidence he expressed.</p>
<p><a href="http://francoisaubin.files.wordpress.com/2008/01/bushratings2.gif" title="Bush Approval Ratings"><img src="http://francoisaubin.files.wordpress.com/2008/01/bushratings2.gif?w=500" alt="Bush Approval Ratings" /></a></p>
<p>This graph shows the evolution of George W.  Bush’s approval rating over time. His approval rating rose to 68% in March 2003, at <span id="more-43"></span>the beginning of the Iraq war, and declined steadily after that. It is now at 26%. Not only did the war not proceed the way he had told people but there is a growing number of Americans questioning the idea of going to Iraq in the first place.</p>
<p>How to lead?<br />
<b> First: be right</b><br />
No matter how good you are at executing and communicating, and how much charisma and resolution you have, if you are wrong, you will fail.  Churchill was resolved but he was right. In the hiking story above, the leader was sure of himself but wrong. He overestimated how lost we were.<br />
To be right, you need facts.<br />
In real life, we do not know with certainty the actual situation. In the context of uncertainty (most real life situations), the more certain you are the more likely you will be wrong. Facts are even more important in uncertain situations. Why? What you know and what don’t know are facts. &#8221;I am lost in the forest&#8221; is a fact. If the leader in the hiking story would have admitted the true level of uncertainty about how lost we were, he could have proposed a series of tests.   For example, he could have propose a short walk in a different direction to gather more facts about the current location. A negative result would then have been seen as new information on where not to go instead.<br />
<b> Second: Communicate facts (reason for change)</b><br />
It is very difficult to convince people to change something if they are not convinced about what the problems are and their urgency, see <a href="http://www.johnkotter.com/index.html" title="John Kotter"> John Kotter</a>.  Two economists might disagree even if they use the same economic model. By separating fact from opinion, we might understand the input or assumption and understand why those economists disagree. Whenever you make a decision where people must follow your lead, facts are the essence of getting people agreeing on the current situation and the course of action.<br />
In business transformation (<a href="http://francoisaubin.com/2007/09/05/change-management-a-catch-22/" title="Catch 22 Change Management">change Management</a>), facts are more than data &#8220;Not everything that counts can be counted, and not everything that can be counted counts.&#8221; (Sign hanging in Albert Einstein&#8217;s office at Princeton), facts are like an observable situation that can be described and shared.</p>
<p>Once facts are gathered and separated from opinion, they can be shared during working sessions.  Those sessions permit the group to agree on problems. Consequently, it will be much easier to get the group to agree on a course of action once they have agreed on the problems. During those working sessions, the focus is first on the current situation, not the course of action. Ensure everybody that they are respected and never discard people expressing bad news (don’t shoot the messenger). Often they might be your best source of facts. To ensure the free flow of information, remove red tape, formal presentation and favor a more informal organization with a high degree of respect, see &#8216;<a href="http://www.businessweek.com/magazine/content/07_52/b4064096006603.htm?chan=search" title="Desth to Bureaucracy">&#8216;The Death to Bureaucracy&#8221;</a> from <a href="http://en.wikipedia.org/wiki/Jack_Welch" title="Jack Welch">Jack Welch</a>.<br />
<b> Third: gather more facts</b><br />
Often, you need to collect more facts. Creativity and imagination are required to gather facts. For example, in the above story, a series of short walks in different directions is an approach to gather more facts on the current location. Gathering facts is boiled down to: observation, experiment, calculation and simulation. Fact gathering is not a consensus driven process. You are collecting evidence. Never rely on opinion. Humans are biased and opinions rarely correlate with facts.<br />
In business transformation initiative, the best sources of fact are field studies. The field is rich and wild; people develop very sophisticated tactics in real work environment. Knowledge lies in the field, not in meeting rooms.  The worst source of facts is the traditional hierarchy : line manager, director and executive. Facts gathered through this path will surely be altered, trimmed down or hidden.<br />
<b> Fourth: prevent bias</b><br />
Facts may be distorted. When relying on human sources, multiple independent sources are required. Be careful with surveys or focus groups, they do not gather facts but opinions. They provide the tip of an iceberg. Avoid group meetings. Groups are only good to solve problems, to brainstorm or share information.<br />
Objectivity does not exist; you have to cope with that.<br />
No matter how good the information is, if you are biased, or already convinced of the answer, you are in danger.  A bias could, for example, lead one to accept or deny the truth of a claim, discard evidence or look for evidence that confirms a preconceived idea (confirmation bias).  In the hiking story, the guy seemed so sure of himself that we trusted him even if the direction he gave did not ring a bell to us.<br />
To reduce bias, observe yourself to see if you feel emotional. You need to detach yourself. It is well known that a lawyer should never defend himself or a medical doctor should never diagnose himself. Ask different persons in a one on one session to interpret facts. Don’t give them your thoughts. Observe the difference in their interpretation. Try to think as fresh as you can. Gather all facts prior to a decision. In order to avoid bias, good investigators will collect evidence and then conclude. After all this work, let the decision emerge naturally. If you still do not feel not comfortable, your instinct will tells you there is something wrong, listen to it. It means there are still uncertainties that you have to work with, or simply wait.<br />
The four steps described here relate to making the right decision and communicating that decision (vision) to a group of people. Once you have the right direction  and a group of people agreeing with you on the course of action, executing change is a piece of cake.<br />
Leading people in the right direction requires hard work, time, experience and wisdom. You can get there faster by practicing the right thing.  For more on the subject, I suggest reading <a href="http://www.johnkotter.com/index.html" title="John Kotter">John Kotter </a>on this subject and “Engineering psychology” by   <a href="http://http://www.amazon.com/Engineering-Psychology-Human-Performance-3rd/dp/0321047117/ref=pd_sim_b_img_4" title="Christopher Wickens">Christopher Wickens.</a></p>
<p><a href="http://francoisaubin.files.wordpress.com/2008/01/bushratings.jpg" title="Bush Approval Rating"><br />
</a></p>
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			<media:title type="html">Frank</media:title>
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			<media:title type="html">Bush Approval Ratings</media:title>
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		<title>Human Error Part 2: Management Error</title>
		<link>http://francoisaubin.com/2007/07/28/human-error-part-2-management-error/</link>
		<comments>http://francoisaubin.com/2007/07/28/human-error-part-2-management-error/#comments</comments>
		<pubDate>Sat, 28 Jul 2007 21:13:19 +0000</pubDate>
		<dc:creator>Francois Aubin</dc:creator>
				<category><![CDATA[Alphonses Chapanis]]></category>
		<category><![CDATA[Cognitive Egonomics]]></category>
		<category><![CDATA[Cognitive Engineering]]></category>
		<category><![CDATA[HCI]]></category>
		<category><![CDATA[Human Computer Interaction]]></category>
		<category><![CDATA[Human Errors]]></category>
		<category><![CDATA[Human Factors]]></category>
		<category><![CDATA[James Reason]]></category>
		<category><![CDATA[Paul M. Fitts]]></category>
		<category><![CDATA[User Experience]]></category>

		<guid isPermaLink="false">http://francoisaubin.com/2007/07/28/human-error-part-2-management-error/</guid>
		<description><![CDATA[You arrive at home after a long day and you rush to prepare food. You turn-on the burner but oups !, you realize that you activated the wrong burner. You feel frustrated and tell yourself &#8220;I should have paid more attention&#8221;. If it is a new stove, you might tell to yourself &#8220;I should have [...]<img alt="" border="0" src="http://stats.wordpress.com/b.gif?host=francoisaubin.com&blog=509005&post=28&subd=francoisaubin&ref=&feed=1" />]]></description>
			<content:encoded><![CDATA[<p class="MsoNormal"><span style="font-family:Verdana;">You arrive at home after a long day and you rush to prepare food. You turn-on the burner but oups !, you realize that you activated the wrong burner. You feel frustrated and tell yourself &#8220;I should have paid more attention&#8221;. If it is a new stove, you might tell to yourself &#8220;I should have look at the instructions&#8221;. Some might even blame themselves for this error.</span></p>
<p class="MsoNormal"><span id="more-28"></span><span style="font-family:Verdana;">Sounds familiar, you’re not alone. Almost all users of the classical stove design, as showed in figure 1, activate the wrong burner at one time or another.</span></p>
<p class="MsoNormal">&nbsp;</p>
<p class="MsoNormal"><span style="font-family:Verdana;">Why?<span>  </span>It is in the human nature to associate objects that are side by side. As showed in the figure 1, the controls of the back burners are closer to the front burners. We cannot tell witch control activates what.<span>  </span>This layout is highly error prone.<span>  </span>To ensure we activate the right burners, we need to pay attention and look at the instructions. See also <a href="http://www.jnd.org/books.html#426" title="Design of everyday things">Don Norman’s Design of Everyday Things.</a></span></p>
<p class="MsoNormal">&nbsp;</p>
<p class="MsoNormal"><a href="http://francoisaubin.files.wordpress.com/2007/07/classicallayourt1.jpg" title="Figure 1. Classicl Stove Layout"><img src="http://francoisaubin.files.wordpress.com/2007/07/classicallayourt1.jpg?w=231&#038;h=202" alt="Figure 1. Classicl Stove Layout" height="202" width="231" /></a><br />
<span style="font-family:Verdana;">Fig.1 Classical Stove Design</span></p>
<p class="MsoNormal"><a href="http://francoisaubin.files.wordpress.com/2007/07/newlayout.jpg" title="Figure 2. New Stove Layout"><img src="http://francoisaubin.files.wordpress.com/2007/07/newlayout.jpg?w=237&#038;h=217" alt="Figure 2. New Stove Layout" height="217" width="237" /></a><br />
<span style="font-family:Verdana;">Fig 2. New Stove Layout</span></p>
<p class="MsoNormal">&nbsp;</p>
<p class="MsoNormal"><span style="font-family:Verdana;">With the layout presented in figure 2, there is no confusion.<span>  </span>Association of control with the burner is now easy because the layout of control is compatible with the layout of the burner. </span></p>
<p class="MsoNormal"><span style="font-family:Verdana;">This example demonstrates design can play an important role in preventing human errors. A design that respects human’s nature and limitations will reduce the likelihood of errors.</span></p>
<p class="MsoNormal">&nbsp;</p>
<p class="MsoNormal">&nbsp;</p>
<p class="MsoNormal"><strong><span style="font-family:Verdana;">Human error in managing human error </span></strong></p>
<p class="MsoNormal"><span style="font-family:Verdana;">After having done hundreds of interviews with managers, we observed when discussing employee’s errors, most managers:</span></p>
<ol>
<li><span style="font-family:Verdana;"><span></span>Blame employees for lack of attention or for lack of training (practice).</span></li>
<li><span style="font-family:Verdana;"><span></span>Overlook the possibility of preventing errors by a redesign of workstation or processes.</span></li>
</ol>
<p class="MsoNormal"><span style="font-family:Verdana;"><!--[if !supportEmptyParas]--><!--[endif]--> In our highly advanced technological society, we are still at the <strong>Stone Ages</strong> in term of human errors management</span></p>
<p class="MsoNormal"><span style="font-family:Verdana;">The stove example is the tip of the iceberg. Human errors are everywhere; from day to day errors such as trying to pull a door that should have been pushed to high impact errors such as: being attentive on the wrong signals and crashing a plane killing hundreds of people, having the wrong information and making bad investments, forecasting the wrong economics figures, misjudging intelligence report and brining a nation to war, making the wrong medical diagnosis, underestimating a budget for a project and being insouciant of consequences of our action on the environment.</span></p>
<p class="MsoNormal"><span style="font-family:Verdana;">Most of those errors, boils down to a combination of human errors that are at the cognitive level. They are errors of detection, attention, planning, estimation calculation, judgment, decision, comprehension, discrimination and execution. </span></p>
<p class="MsoNormal"><span style="font-family:Verdana;">Although aircrafts are still crashing, the safety record of the aviation industry is impressive when compared to other industries.<span>  </span>At the end of World’s War 2, the aviation industry realized, following the pioneer work of <a href="http://en.wikipedia.org/wiki/Alphonse_Chapanis" title="Shapanis">Alphonse Chapanis </a>and <a href="http://en.wikipedia.org/wiki/Paul_M._Fitts" title="Fitts">Paul M. Fitts</a>, that human errors were caused by subtle inherent human cognitive limitations. The Aviation industry stopped blaming pilots or maintenance personnel for human errors decades ago. They tried to understand the inner cause of human errors.</span></p>
<p class="MsoNormal"><span style="font-family:Verdana;">This demonstrates it is possible to move away from the <strong>stone ages</strong> in a few decades. Managers need to stop limiting explanation of human errors to the lack of attention, lack of training or poor personnel selection and expand their analysis of to the real nature of human errors.</span></p>
<p class="MsoNormal"><span style="font-family:Verdana;"><!--[if !supportEmptyParas]--> <!--[endif]--></span></p>
<p class="MsoNormal"><span style="font-family:Verdana;"><!--[if !supportEmptyParas]--> <!--[endif]--></span></p>
<p class="MsoNormal">&nbsp;</p>
<p class="MsoNormal">&nbsp;</p>
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			<media:title type="html">Figure 1. Classicl Stove Layout</media:title>
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			<media:title type="html">Figure 2. New Stove Layout</media:title>
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