Errors of judgment

Among tlie phenomena tliat lead to accidents, human error is tlie most unpredictable. Tliis section describes accidents due to errors of judgment. Even well trained people occasionally make such errors, and one must eitlier accept an occasional mistake or cliange tlie work situation to ininiinize or remove tlie opportunities for error. 

At times in this book, I may appear to have been too sympathetic to the operators -for example, Colin Seaton on Piper Alpha, or Captain Khowhyter on Saudia 163. My reason for being sympathetic is that I have been a shift manager of a nuclear power station, and I know how easy it is to make errors of judgment when things go wrong. 

As you read through the descriptions, do not try to memorize every cognitive bias. Rather, study how these biases function in decision making. Look for how they enable a person to move forward in the face of uncertainty and how they can also produce errors of judgment. 

We know that dislike for a patient can easily incline treatment team members to errors of judgment. Disliking a patient can predispose team members to avoid the patient, not listen to him, cut his communication short, and be insensitive to the significance of his complaints. Groopman points out that we don t like patients... 

Despite our best intentions, the way we process information sets us up for errors of judgment. We now know that we can take steps to protect ourselves from such errors. Although each of us must work on this challenge ourselves, we need not work alone a culture that encourages bias detection and examination provides perhaps our best defense against the problems these biases can cause. But how do we build such a culture ... 

It is very difficult indeed to interpret the significance of these observations but it would appear to the writer that the most important question is to know whether the three synthetic estrogens mentioned above represent the most active substances that can be obtained. If we return to our first introductory remarks— namely the purely logical and scientific approach to these problems, we are at once confronted with the undeniable fact that these three substances, whilst apparently resulting from a planned and orderly research, really resulted from an error of judgment and that the path which led logically to anol—which incidentally proved to be of very low activity—was by chance led from anol to stilbestrol. 

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