failure analysis tactics and cognitive bias

Lorri Zipperer Lorri at ZPM1.COM
Thu Aug 15 18:30:12 UTC 2013

My colleague Dean Hooper shared these thoughts on my query.


I thought they'd be useful to include in our discussion here. Lorri


“What a healthy, useful, politically incorrect way to look at the problem!! In his seminal paper from the '83 NATO conference on human error, Hollnagel called for the focus of error not to be the error itself, but the mental mechanisms we use to solve problems. Rasmussen subsequently created a taxonomy labeled "mechanisms of error" as direct causes of adverse events. These mechanisms were such thing as inference, deduction, information processing, etc. The researcher then looks at these mechanisms to figure out what went wrong. I don't know of anyone else that comes close to formalizing cognitive bias as immediate cause. I've always thought Rasmussen's terms were too broad. Using cognitive bias as a cause could add some precision, I would definitely like to discuss this further and hear what others have to say. 


PS Politically incorrect in that HF'ers don't like to look at the human as the source of error. Of course, you would still have to assess what caused the bias in the first place in order to determine effective mitigations. 


Dean Hooper

Principal at HE Consulting LLC

dean.hooper at “


On Aug 14, 2013, at 4:06 PM, Lorri Zipperer <Lorri at ZPM1.COM> wrote:

I wondered if anyone has used system failure analysis techniques (5-whys, FMEA, RCA, etc) to identify cognitive biases (ie availability, confirmation, anchoring) and subsequently design mechanisms/strategies to reduce the impact of cognitive bias on decision making. 


 Lorri Zipperer, Cybrarian and editor

Zipperer Project Management 


Patient Safety: Perspectives in Evidence, Information and Knowledge Transfer

ISBN 978-1-4094-3857-1 


Knowledge Management in Health Care

ISBN: 978-1-4094-3883-0

lorri at



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