This week’s thoughtdrop has a slightly more sombre tone than usual. We will discuss an important issue which can have serious consequences. This thoughtdrop will discuss Distraction. It will explore how distraction is a human trait that causes problems in many settings. We’ll also discuss what you can do so there’s less chance that distraction will cause you and your team problems. Please bear in mind this thoughtdrop is aimed at people from a variety of different professions and environments – as such I have taken the liberty of simplifying some of the technical language.
The Curious Case of Phineas Gage
In September 1848, Phineas Gage was clearing rocks for a new railway line in Vermont in the United States. Part of the job involved drilling holes into rocks and then using a long metal rod to force dynamite into the hole, so the rock could be blown apart. Unfortunately, Phineas became distracted by his workmates and turned around, while placing his head over the rod. At the exact time he turned around, the dynamite exploded, and the rod shot out of the rock. The rod travelled through Phineas’s left cheek and exited through his head.
People were amazed because, somehow Phineas survived, but people were also intrigued. Because although physically he was fine – with the exception that he had lost sight in one eye, his personality had changed. Before his accident, Phineas was the team supervisor and he was known for being disciplined and well mannered; after his accident Phineas seemed to lose his inhibitions and would say inappropriate things and became disagreeable. He also lost some of his memory function, for instance he could not remember the names of some of his long-time friends.
As a psychologist with a specialist interest in behaviours at work, I’m fascinated by the story of Phineas. While most psychologists are interested in Phineas’s apparent behavior change, I’m just as interested in the situation that led to his injury; namely Phineas was distracted by his work mates.
Distraction in Aviation
And over a hundred and fifty years later, distraction at work is still a major influence in workplace accidents and incidents. The potential for distraction to cause injury or mishap is well known in aviation, where pilots, maintenance engineers and air-traffic control operators are taught about the Dirty Dozen – twelve key human factor influencers of poor outcomes; of which Distraction is one of the 12 culprits.
Distraction might cause people to lower their awareness and miss hazards or forget to do essential actions. Distractions due to crew members getting caught up in conversation might have relatively harmless but embarrassing outcomes, such as flying 100 miles past the intended destination (1). But distraction can produce more tragic outcomes. For example, consider the case of cargo Flight 1353 from Louisville KY to Birmingham AL which crashed into trees before it reached the runway, taking the life of both pilots. The investigation found many causes, including the pilots not noticing that the wrong flight plan was entered into the Flight Management Computer. The investigation pointed to the pilots holding a conversation which distracted them from the cues available and the expected routine task of verifying the flight plan (2). There are plenty of other ways pilots can be distracted, such as being interrupted by cabin crew during the pre-flight checklists. A distractor does not need to be a person. Indeed it can be a piece of equipment, such as a faulty warning light; illuminating for no clear reason. A faulty light can lead pilots to divert all their attention to the apparent problem. In one extreme case, the pilots became so distracted with a faulty light that they failed to correctly control the descent of the plane, with the result that the plane crashed (3).
Distraction in Healthcare
Episodes of distraction can be found in healthcare too. In an excellent paper, Judy Smetzer and her co-authors (4) reflect on the case of a 16 year-old patient who was taken into hospital to deliver her baby. A nurse was put in charge of getting the young mother ready for a spinal anaesthetic. We can assume that the nurse was a caring professional, because we know that she spent two hours talking with the girl and her mother about family dynamics and trying to alleviate anxieties about the delivery – which was going to involve an injection into the spine. We also know that the nurse had volunteered to cover shifts for absent staff, and the previous day had worked a double shift, resulting in the nurse working for 18 hours. No doubt fatigue played a significant part when the same nurse inadvertently, picked up, and gave the young to-be-mother the incorrect drug by an infusion pump. Instead of pumping in an antibiotic to take care of a Strep infection, the nurse had set up a cocktail of painkilling drugs normally used in the spinal anaesthetic. The mix-up resulted in the patient having a cardiovascular collapse. Although the doctors were able to save the baby, the child’s mother lost her life. The investigation found that the nurse was continually distracted during her care for the girl, with continuous interaction with the patient and other visitors in the room.
Distraction in Oil and Gas
One final example from another industry will illustrate how distraction can cause issues in a variety of settings. In offshore drilling the driller and his team use multiple pieces of long pipe (called a drill string) to go down under the sea and drill into the seabed. In one episode (5) while the driller was pulling out the pipe, he became distracted by someone trying to talk with him, with the result that the top of the equipment (called a top drive) holding the drill pipe struck the pulley at the top of the frame that was holding it (the crown). Luckily no one was injured despite bolts and broken metal falling over a 100 feet onto the work area below. Drilling rig’s are high hazard environments where a lapse in concentration can be deadly – it’s thought that over a third of drilling accidents are related to an inadequate level of awareness.
We know that distraction can be a problem across many industries. So what can industries learn from each other? Sterile Flight Deck
Aviation uses a ‘Sterile Flight Deck’ rule which restricts flight crew members from doing anything except their essential duties that they need to perform. Duties that require strong focus at specific times, such as - taxi out, take off, initial climb, final approaching, landing and taxi in. If you are not in aviation, can you apply the sterile deck rule to any particular phases of your team's work?
Do Not Disturb Can you take stronger, clearer measures to let people know when your team members are not to be disturbed? For example, nurses in some hospitals wear tabbards saying ‘do not disturb’ when dispensing medication. Do you need to have the equivalent of an ‘on air’ sign to let people know they should be quiet in a certain area?
Take a Note
The biggest influencer of forgetting to do something at work is distraction. If people are disturbed when carrying out a task with multiple steps, then they should make an effort to write down the last step they completed; so they know which step to go back to, if it’s a lengthy interruption.
Appreciate Individual Differences Some people like some noise in the background, such as a radio playing, they find it helps them relax and work. Other people will find it difficult to concentrate intently with any real level of noise. Get to know what people prefer and where possible, accommodate individual differences.
A Special Plea to Offshore Drilling Teams
One area where I have frequently seen the potential for work related disturbance is offshore driller’s shacks. Offshore drilling rigs enforce a Red Zone in the area where the drill team works. The Red Zone is an area that is rigorously guarded, so only people who are supposed to be working in that area are allowed to go inside, due to its high hazard environment. But the driller works just outside of the zone, sitting inside a room, separated from his team by a large window. He sits in his drilling chair, skilfully pushing joysticks and pressing pedals, while operating millions of pounds worth of equipment. A lapse of concentration could be deadly for his team. And yet, the drillers are constantly disturbed by people outside of their team. The only real restriction to someone coming into the drill shack and directly disturbing the driller, is the general advice that people should phone the drill shack before visiting – a piece of advice often ignored. More often than not, it is the driller who will answer the phone, while operating his machinery. Think about that for a moment; A person operating millions of pounds of equipment, and who needs to concentrate to keep his team safe is expected to pick up a telephone. And yet, in many countries even when Joe Public is driving on the motorway he is not supposed to pick up a phone due to the affect it has on her or his attention. As such I implore the drilling industry to take up the challenge of reducing distractions for drillers. --------------------- The story of Phineas Gage is an extraordinary tale from over 170 years ago; and yet Phineas's experience still resonates today. My hope is that we continue to learn and reduce potential distractions as far as is practicably possible; and at some point in the near future we will no longer harm people because of distraction. #harenssthehumanfactor This article is for education purposes only and may be freely used 1 - https://www.skybrary.aero/index.php/A320,_en-route,_Denver_CO_USA,_2009 2- https://www.skybrary.aero/index.php/A306,_vicinity_Birmingham_AL_USA,_2013 3 https://en.wikipedia.org/wiki/Eastern_Air_Lines_Flight_401 4. https://qsen.org/wp-content/uploads/2019/07/Smetzer-article-2010.pdf 5. https://www.iadc.org/safety-alerts/alert-03-34-preventing-crown-collisions/
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