ExposureBlog

Human Error researcher James Reason claimed that human beings can consciously process, at most, about five different things at one time.  Unconsciously, they rely on learned behavior.  One example: driving down the road on a clear day with few distractions.  That’s learned.  Then the cell phone rings.  That’s new, and that’s ONE new item.  Suppose the driver has programmed the phone to produce a special ring that is associated with a certain caller.  If that particular ring sounds, then the driver knows it’s that caller.  That’s when the conscious links to that caller come into play.  That’s the second thing added to the agenda that the consciousness has to deal with.  If the links are extensive and associated with problems (i.e. the driver’s accountant, parole officer, etc) then the space in the “consciousness clipboard” begins to fill up rapidly. 

Now, suppose this happens to be a new cell phone (the driver lost the other one because a clip failed and also because he had gained weight forcing the cell phone FROM his belt and onto the floor.  Or ground.  Somewhere.  Bottom line, he isn’t sure how to use it.  Worse, the phone is a little Sanyo model with the camera button on the right edge–so when he knows that when retrieves it from his belt he runs the risk of hitting the button, taking a picture of the floorboard of his car—and losing the connection.

Conscious things to consider: Three. 

Now, he’s driving down the road at 88 miles per second, one hand on the steering wheel, one holding the phone.  Before he’s even started the conversation 60% of his available conscious attention has already been used up.

Then, he begins the conversation–one that will likely take up at LEAST another 20%–and probably more.  In fact, if the caller presents the driver with only two problems to solve, that’s probably more than he will be able to deal with properly.

In heavy rush hour traffic plugging along at 20 miles per hour (Goodyear Blimp speed) it probably won’t cause much of a problem–beyond a fender-bender.  At sixty miles an hour, funny things can happen. 

For one thing, that unnamed entity of the subconscious driving the car might think the driver is running late and want to solve the problem by speeding up a bit.  Or a lot. 

I haven’t done a survey (scientific or not) to determine this, but where I live it seems the ones driving the fastest, are the ones using cell phones.  I once saw a guy blast through a Starbucks parking lot at around 30 mph–narrowly missing cars and people–and he was talking on a cell phone.

If you object to the “5 things” limit (”surely I can multitask better than that!”) drive on over to the nearest four-way stop that involves dual lanes of traffic.  That is, intersecting streets EACH with four lanes of traffic (two in each direction.) Here, the driver is presented with eight things to evaluate. See how easy it is to keep track of everything?  Notice if any of the drivers jumped their place in line?

I think Reason’s work explains a lot about safety and about how accidents happen.  The conscious clipboard just fills up.  Forget Root Cause Analysis, just count the threads being processed. 

More on this later.

Since many cases are won or lost on the testimony of eyewitnesses, a recent study cited here should raise some eyebrows.  It concerns the psychological phenomenon known as inattentional blindness, or the inability of some normal individuals  to recognize something when their attention is directed elsewhere.  The phenomenon is well-known in psychology. Visual expert Marc Green has a good article on inattentional blindness and human error,  and there is a book on the subject by Australian researchers Arien Mack and Irvin Rock.

I have read depositions in which the deponent is asked over and over whether he or she saw something take place.  If the response is in the negative the assumption is that the event did not, in fact, occur—or that those who say that it did are not telling the truth.  Well, not so fast.

In the study, conducted by Dr. Seema L. Clifasefi of the University of Washington at Seattle, 47 participants were asked to watch a basketball game and count the number of times a basketball was passed back and forth between teams.  Some were given an alcoholic beverage and others were given an alcohol-free beverage.  During the game, a woman in a gorilla suit appeared on the screen, stood amidst the players, beat her chest and walked away.  When questioned later whether they had seen the gorilla, fully a third of the participants had NOT noticed the gorilla.  Of those not consuming alcohol, only 46% recalled seeing the gorilla.  Of those consuming alcohol, only 18% recalled the gorilla.

It would seem, then that if an eyewitness was engaged in behavior that required his full attention, the odds of noticing details of a specific incident may be less than 50 percent. 

Suppose you’re a plaintiff lawyer with an injured client.  You suspect the defendant, a large construction company, has some very bad work practices that put employees of subcontractors at risk.  You only have so much time and funds available.  After the eyewitnesses—and of course, the safety guy—who should you depose? 

Some of of my clients on the Plaintiff’s side like to go top down–deposing the CEO or the President of the company first, then work their way down to the managers.  Others prefer to work their way up–foreman to supervisory personnel.

At some point–usually with the mid-level managers they will encounter something like dense fog obscuring all further discovery: the malady known as CCA: Command Chain Amnesia.

While you or I might remember inconsequential meetings with people that took place years ago—and may even remember what was said, there are highly-paid people working as managers who won’t remember talking with anyone.  They will be unable to recall meetings, conferences and even what they took in college.  One president for a VERY large Texas construction company claimed on the record that he didn’t really know anything about electricity (the case involved an electrocution.)  When it was pointed out that he also had an engineering degree, he said he couldn’t recall taking any courses that had to do with “electricity.” 

Amnesia isn’t limited to the corporate world.  A CIA analyst by the name of Tyler Drumheller is writing a book that will no doubt shine a bright light on command chain amnesia in the run-up to the Iraq conflict.  It seems he told both his boss, a man named John E. McLaughlin as well as the Director of the CIA himself that the intelligence regarding weapons of mass destruction was seriously flawed–well before the information was used in speeches by both the President and by the Secretary of State.  When asked to comment, neither McLaughlin nor Tenet could remember ever talking with Drumheller. 

So, I suppose it’s a waste of time to be angry with the mid-level managers when they fail to remember important details.  It seems to affect the big guys as well.  There are, of course, few things that can be done to make someone remember something, especially when doing so makes them look foolish. For the person asking the questions, this can pose a real problem.

I did hear once about a case in which a feisty trial lawyer (is there any other kind?)–after hearing a deponent repeat “I don’t remember” for about four hours—finally demanded to see the man’s medical and personnel records.  Seems he wanted to find out if they guy was taking drugs that would cause amnesia—or in the alternative, why a company would even hire someone who couldn’t remember anything. 

Thankfully, command chain amnesia doesn’t usually cause problems for the those who have it.  Some, like George Tenet,  go on to win the Presidential Medal of Freedom.

The Plaintiffs in this series of trials think so.  Former Corpus Christi welder Ernest J. Solis is the plaintiff in a trial being held in Cleveland.  His is one of 3,800 other lawsuits regarding Parkinsonism and welding fumes that have been consolidated in federal court there.  The toxin alleged to cause the Parkinsonism is manganese, an element occasionally found in welding fume–and, oddly enough, nuclear fallout.  Manganese is certainly a neurotoxin, but the symptoms it produces are fairly specific and don’t always correlate with classic Parkinsonism. According to Leikin and Paloucek, in the well-regarded (by me anyway) Poisoning and Toxicology Compendium, manganese-toxic patients “have a tendency to fall backwards, not have a prominent tremor and do NOT respond well to dopaminomimetic medication as opposed to idiopathic parkinsonism patients.” I’m betting one of the experts for the defense in this case will be Denver physician Scott D. Phillips.  He wrote an article in Greenbergs Occupational, Industrial and Environmental Toxicology, in which he had this to say about manganese: “Symptoms (of manganese exposure) are typical of parkinsonism. However, the brain lesions from manganese occur in the striatum and palladium in distinction to parkinsonism, in which the substantia nigra is damaged.”  He cites A Barbeau et al, “Role of manganese in dystonia,” Adv Neurol. 14:339, 1976.  Damage to the striatum and palladium is something that, presumably, can be differentiated from damage to the substantia nigra.

Then there’s the issue of naturally-occuring manganese in the environment.  For example, an average cup of tea may contain 2-7 ppm of manganese.

Making matters even more difficult for the Plaintiffs, the conditions of exposure to welding fume are going to be difficult to quantify years after the fact, especially when there may be no clear record of the specific types of welding rods that were used over the time period.  I can imagine the request for production: “all invoices for welding rods going back to 1960, all industrial hygiene monitoring results from 1970 to the present. . .”

Of course, I haven’t seen the court documents, but if the Plaintiff is asserting that welding rods -> manganese -> Parkinsonism in the welder, then it might be a tough case to make.

Prediction: 8:4 Defendant.

A young woman enters a hospital to give birth, gets an epidural and dies.  The hospital denies any wrongdoing, but there seems to be a lot of evidence to the contrary.  Read the article and decide for yourself.  I’m also including a link to RID, Reduce Infection Deaths.  Worth looking at.