The Risk Of Routine

Sometimes being on autopilot—knowing a skill so well it doesn’t require conscious thought—can lead to human error.

Learning & Development (L&D) professionals need to heed findings from neurologists and psychologists when performing job task analyses or writing course curricula for any service job’s routine procedures. These experts note that sometimes being on autopilot—knowing a skill so well it doesn’t require conscious thought—can lead to human error.

Neurologists explain that we have two regions in our brain, each capable of performing routine tasks. The region that normally takes control of routine tasks is the basal ganglia (BG). They’re a set of structures located at the base of our brain, just above the brain stem. After we’ve repeated a task many times, the skills and behavior associated with performing it get stored in the BG as long-term memory. When this happens, we say that such a routine is now part of our habit memory—in other words, we’re functioning on autopilot.

But first, we need to back up to when we initially learn a procedure or skill, such as driving the same route to work or riding a bike. At the initial point in learning a routine, we rely on a different brain structure: the prefrontal cortex (PFC). It’s located behind our forehead, taking up a third of the cortex. It is where our “executive function” resides: We carry out abstract thought, focus our attention, plan, evaluate, judge, and store key information relating (as working memory) to whatever it is we’re attending to at the moment. Our PFC does all the figuring out of what needs to be done when we learn a new skill, procedure, or behavior. It is aided by the hippocampi (HC)—a set of structures in the temporal lobes that form, organize, and store facts and events for possible future use.

But as the steps and nuances of skill performance get easier through repetition, our PFC hands off the memory of how to execute it to the BG. In handing it off, we’re consciously freed up to attend to our next prospective procedure, skill, or behavior. Put another way, our PFC, aided by the HC, is referred to as our prospective memory system. This keeps it distinct from our habit memory system, which is unconscious, by the way. In the workplace, when we see someone operating on autopilot, that’s his or her habit memory in control.

A WORLD OF DISTRACTION

Why is this so important to performing routine service tasks, for example? Mainly because we are easily distracted by all manner of stimuli in an environment. We get interrupted by fellow workers, the boss, etc. We take breaks or we multitask. All these are contributing factors to human error: an omitted step, forgetting a key piece of information, getting the order of steps wrong, etc. Where customers are concerned, the stakes for error can range from minor inconvenience to catastrophic outcomes.

Some potentially tragic examples of errors following on the heels of routine procedures include:

  • A pilot forgets to set the wing flaps for landing or lower the landing gear.
  • A surgeon forgets to remove sponges or instruments from a patient or performs a procedure on the wrong limb.

The same common denominator precedes the usual slips and lapses during routine procedures—the habit memory system. As soon as a distraction happens, or during multitasking, this system breaks down. That’s because we’re then temporarily focused on the distraction or on some other concurrently performed task. By focused, I mean we’re consciously attentive—in using our prospective memory system, we’ve broken the connection with habit memory. With our prospective memory now in command, we then attempt to return to the original procedure afresh, but instead find ourselves lost on the details of where we left off and exactly what still needs doing. This “unplanned handoff” is what leads to failure to execute.

INSTITUTE PREVENTIVE SAFEGUARDS

This phenomenon has substantial implications for the L&D community: specifically, instructional design and training workshops focusing on routine tasks that have high stakes with costly and catastrophic human consequences for human error. Service industries such as healthcare, pilot training, offshore oil exploration, and utilities are particularly vulnerable. An “if-then” rule-of-thumb needs to be in force for all L&D projects: If high stakes are involved for human error, then augment the training with recommendations for instituting preventive safeguards. Decisions about which safeguards to use should be based on work context and whether safeguards are to be installed at the individual worker or work unit level.

Individual workers could use something as basic as sticky notes or a clipboard to jot down a last step performed when they are suddenly distracted or interrupted. For unit-wide safeguard deployment, common strategies could include:

Backup: A coworker steps in when an employee is called away to an important, can’t-wait matter.

Call Outs: Calling out the last step performed improves auditory memory.

Checklist: This basic job aid sometimes is ridiculed, but it is highly effective.

Delay Interruption: Ignore an interruption until a natural breaking point in the task is reached.

Do Not Disturb or No Interruption Zone: Post signs to that effect at point-of-task (PoT).

Policies: The organization sets formal policies pertaining to specific distractions or interruptions at PoTs.

PoT Setups: Ensure all resources are in place before beginning a task, eliminating “self-interrupting.”

Although working on autopilot is economically advantageous for our brain, it is real-world risky. It’s safer if we stay consciously focused on whatever it is that we do.

Benjamin E. Ruark is a former Learning & Development, Continuous Quality Improvement specialist/consultant to a half-dozen manufacturing and service industries. He has worked extensively in the U.S. and abroad, including the UK and Ireland.