Confirmation Bias - What You Can Do

CONFIRMATION BIAS - WHAT YOU CAN DO!
Conrmation Bias What you can do

3 problems
1. 2. 3.
We are only human We cant help ourselves Bystanders can help but choose to do nothing
What you can do
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Mental Models + Conrmation Bias + Bystander Effect = Disaster

The Kegworth air disaster in 1989 cost 47 lives and resulted from the ight crews management of a mechanical incident in one of the engines. The 25th anniversary of the accident gives an opportunity to reect on the causes and, perhaps, what we would have done, should have done, as passengers on that plane.
Problem 1 - We are only human

The ight crew identied a malfunctioning engine. The evidence they used to identify the faulty engine was false and they shut down their one good engine, the right hand one. They then attempted to land at a nearby runway. By the time they had realised the error it was too late. They crashed a half mile from the runway. The ight crew s mental model of what was happening was wrong. Human factor professionals point to the problem being a awed mental model.
(Professor Rhona Flin explains the model in the DVD, Unclear and Present Danger)
As humans we are required to process huge amounts of data to perform our daily tasks. And, as humans, we sometimes get it wrong.
Problem 2 - We cant help ourselves

One explanation for the reinforcement of awed mental models is that people tend to wait for data which conrms their mental model. An o!shoot of this is that people overlook data which contradicts their mental model. In the case of the Kegworth accident, the testing by the crew to conrm which engine was faulty happened to coincide with a reduction in the level of the symptoms. In other words, the evidence as they saw it, conrmed for them that the right hand engine was faulty. This is called conrmation bias. (Professor Rhona Flin explains the model in the DVD,
Unclear and Present Danger)
The problem is that we may know what a mental model is and we may well understand the trap of conrmation bias but, out in the eld, that knowledge in itself does not guard us against error.
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Problem 3 - Bystanders can help but choose to do nothing

Research has found that in any situation where someone needs help, as the number of bystanders grows, the probability that any one bystander will help decreases. For many people and many situations it is not a lack of caring but its simply not knowing what they can or should do. In the Kegworth accident, while the ight crews mental model of what was really happening was wrong, some passengers had the correct mental model because it was right in front of their noses. They could see that it was the left engine that was on re. So, naturally, some of these people were concerned when the Captain broadcast the message that he had shut down the right hand engine. But, none of these passengers attempted to intervene or to get a message through the cabin crew to the pilot. Among the bewildered group was a bread delivery man from Dungannon. He said, We were thinking: 'Why is he doing that?' because we saw ames coming out of the left engine. But I was only a bread man. What did I know?"
What you can do How to turn your bystanders into active participants
The denition of a bystander is a person present but not involved. In workplace and process safety everyone needs to be involved. Workers, colleagues and team mates need to know that they are never bystanders. So, in every workplace, management needs to make sure people know: 1. They can say something 2. They should say something 3. They know what to say
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Case study and self evaluation Drug administration error - the patient died
Background The chemotherapy drug Vincristine must be injected into a vein."If injected intrathecally, that is, into the spine, the drug destroys the nervous system. The outcome is nearly always fatal. " In this actual case, the doctor wrongly injected the drug and the young patient died four weeks later. Currently, only three drugs are licensed for intrathecal chemotherapy, that is, injected into the spinal space. One of these is methotrexate. There were two doctors present during this procedure. In the enquiry, one doctor could not explain the fact that he translated the word Vincristine for Methotrexate when it was said by the junior doctor. However, this could be explained by his mental model which was built on the knowledge that drugs for intrathecal administration are not available at the same time as other drugs. The system would not allow it. So, his mental model was tellimg him that this can only be Methotrexate and therefore okay to administer this way. The doctor could not recall a query being raised with him by the junior doctor about the Vincristine. But he said that he would have told him to proceed in any case, believing in his own mind that it was correct to do so. The junior doctor did not challenge the other doctor regarding the decision to administer the Vincristine intrathecally, even though he thought something was wrong. In the enquiry he said, First of all, I was not in a position to challenge on the basis of my limited experience of this type of treatment. Second, I was (junior) and did what I was told to do by the Registrar. He was supervising me and I assumed he had the knowledge to know what was being done. He was employed as a Registrar .. and I did not intend to challenge him.
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Summary The junior doctor: 1. Didnt think he could say something; 2. Didnt think he should say something; 3. Didnt know what to say.
Role play and self evaluation - 1

Assume you are the junior doctor If you were the junior doctor and you had a moment of uncertainty about the procedure being performed, what would you have said to the senior doctor? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Evaluate your participation Do your words show respect for your senior (or your team mate)? Comment ___________________________________________________________________ ____________________________________________________________________ Are you direct and clear? Comment ____________________________________________________________________ ____________________________________________________________________
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Are you assertive? Comment ____________________________________________________________________ ____________________________________________________________________ Have you used facts? Comment ____________________________________________________________________ ____________________________________________________________________ Have you used a probing or challenging question to raise any key issues? Comment ____________________________________________________________________ ____________________________________________________________________ The participants toolkit 1. Be assertive and use I statements Could you please stop the procedure, I have some concerns? 2. Use facts Im concerned that I may have missed something here. It says intrathecal administration but for Methotrexate not for Vincristine. 3. Use a probing question Probing questions generate further information useful to delve into what is happening and raise issues. The usually start with explain, describe, how, why, what, when or who.
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Could you explain what conditions are required for intrathecal administration of Vincristine? Before we proceed, Im afraid I dont fully understand this procedure.Would you mind explaining it to me? 4. Use a challenging question Challenging questions are used to encourage self-reection; What is the evidence to support what I am doing, here?. Are you saying that Vincristine can be injected intrathecally and so what we are doing here is correct?
Role play and self evaluation - 2

Assume you are a passenger on the Kegworth ight If you were a passenger in a position to see that the left hand engine was on re and smoking and you heard the captain say he is shutting down the right hand engine, what would you do? Be a bystander and do nothing? Or, try to get the crews attention? If so, what would you do and say? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________
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Evaluate your participation Do your words show respect for the crew? Comment ________________________________________________________________ ____________________________________________________________________ Are you direct and clear? Comment __________________________________________________________________ ____________________________________________________________________ Are you assertive? Comment ___________________________________________________________________ ____________________________________________________________________ Have you used a probing or challenging question to raise any key issues? Comment __________________________________________________________________ ____________________________________________________________________ The participants toolkit 1. Be assertive and use I statements I would like you get this message to the pilot. It is very important that he knows this. 2. Use facts Please tell the pilot that we saw ames coming out of the left hand engine, not the right. 3. Use a probing question Could you ask the captain to tell us why the left hand engine has ames coming out?
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4. Use a challenging question Are you saying that you are deciding what the pilot needs to know? Are you saying that the pilot would not want to know that the left engine is on re when he has just told us he shut down the right hand engine? 5. Use repetition I am sure the pilot will want to know that .. . So, you must tell him.
Mental models in sport Try the following example for explaining mental models and conrmation bias Football mental model The referee knows what he saw. He saw the outstretched leg of the defender and he saw the player hit the turf hard and writhing in agony. The referee also knows the defender as a hard man in tackles and this conrmed his mental model of what had just taken place. The reality was that the leg made no contact and the tackled player took a dive. But, the penalty was given and the game was lost. But, the referee is always right so dont bother participating youll most likely get a red card. Work place example Select your own work place example and use the participants toolkit to help overcome conrmation bias.
Nicholas and Smith DVD training resources include: Unclear and Present Danger - Situation Awareness at Every Level Fatal Error - Choosing the Wrong Engine BBC Disaster Series Managing Human Error
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Confirmation Bias - What You Can Do

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CONFIRMATION BIAS - WHAT YOU CAN DO!

Conrmation Bias What you can do

What you can do