Why do we make mistakes?

Sitting in a Grob 115A cockpit, at the hold on an empty airfield I ran through the pre-take-off checklist. It was my first time taking a passenger flying, after completing RAF flying training and finishing off the final elements of my civilian licence. I was eager to get airborne, and although there was no pressure to get going, I did feel the pressure of the responsibility of someone else’s life who didn’t have a clue how the aircraft worked. I’d only ever flown next to an instructor, or by myself, so this was a novel experience. As part of the checklist, I acknowledged that I would be leaving the transponder set to 7000 but conducted no further action. Once airborne and speaking to London Control, I was given a squawk of 1177. Immediately as I looked at the blank transponder screen I had realised that I hadn’t even turned the thing on! Fortunately, it was a clear day, I immediately rectified my lapse, and the rest of the flight went without incident. Incidentally I had setup my GoPro in the back of the aircraft and captured the whole ordeal. Watching the footage back I was able to start piecing together some of the human factors that may have contributed to my error.

Human factors are environmental, organisational and individual characteristics, which influence behaviour. They are, quite often, the reasons behind why things happen. While the environmental and organisational characteristics can be influenced, quite often they are out of our direct control. They are external factors which influence our behaviour. The individual, however, is somewhat within our control and we can look at ways to reduce the likelihood of us making mistakes. After all, to err is human, but if we can minimise errors then we are likely to improve in whatever endeavours we choose!

For an action to be described as an error, there needs to be a measurable standard expected, an opportunity to meet that standard and then a subsequent action that fails to meet that standard. Quite often, the environment we find ourselves in, or the equipment we have available to us, prohibit us ever meeting the expected standard. To reduce errors, we need to incorporate human factors into system designs, to reduce the barriers to attaining the standard.

When discussing errors, people quite often use the term mistake interchangeably. Are errors and mistakes the same thing? Almost. Within a just safety culture, we seek to identify where shortfalls occur. It is not a blame culture, nor is it blameless. If actions are genuine errors or mistakes, then so be it. But we must also be aware of actions which are of a malicious nature and look to work out why individuals have chosen to act in such a way. Mistakes and errors come where an action was not an intentional breaking of the rules. If an individual considers risk appropriately and follows the rules and procedures, then the next consideration is if their action was intended. If it was, then we say it was a mistake; they carried out their action correctly, even though it was inappropriate. Errors are when the action was not intended and can be further broken down into slips(appropriate action carried out incorrectly) or lapses (an action was missed or unnecessarily repeated). By missing switching the transponder on, despite saying the right thing, I made a lapse.

If we focus on why we make mistakes and errors, we first need to understand the human cognitive process. That is, the way our brains make sense of the world around us and decides upon the actions to take at any given time.

Our brains are, in themselves, incredible machines. Research indicates we have around 86 billion neurons in our brains, each able to connect to one another, leading to around 1 quadrillion connections. Signals pass along these connections at up to 350 miles per hour. Imagine that level of processing on a computer; developments in artificial intelligence are looking in that direction, however our minds are such a unique, powerful asset. But how do these incredible systems work?

Information is all around us. We absorb this information, or data, through our senses, which register this data and pass it to our working memory for processing. Before this, however, we perceive the data. This perception is a key aspect of our cognition; it is how we interpret the data our senses have registered and determine what we send into our central processing. Without delving too far down the biological rabbit hole, this process can be degraded, for whatever reason, and this cognitive breakdown is the breeding ground for mistakes and errors.

Now to answer the question, why do we make mistakes? Our environment, existing beliefs, equipment, mood, health, previous training, decision making process, physical capability, communication skills, organisational structure, its policy and regulation, those around us, workload and distraction. This is in no way an exhaustive list. Not even scratching the surface. Anything that influences our processing of a situation, can contribute to a breakdown of that processing and a subsequent mistake.

Everyone will make an error or mistake at some point. The best of us learns from that. They acknowledge the factors that caused the mistake and look for ways to prevent them happening again. And when mistakes do happen again, we identify their causes and repeat the process. It is a constant refinement in optimising our environment and processes to be the best that we can be.