The placement of the conjunctions “and” and “or” in the definition of competence are curious. Did the legislator really intend us to think that knowledge along with other undefined qualities were suitable substitutes for training and experience? Surely knowledge is a result of training built upon by experience rather than an alternative route to enlightenment.
So what is knowledge? One dictionary definition (from www.oxforddictionaries.com) is: “Facts, information, and skills acquired through experience or education; the theoretical or practical understanding of a subject.”
The key word here is understanding. We can find information on the internet, in operation and maintenance manuals or data sheets, but it is understanding how to use that detail that makes us knowledgeable. The dictionary definition includes “skills” but a classic model introduced by Danish human factors academic Jens Rasmussen in 1979 and developed by UK psychology professor and risk specialist James Reason in the 1990s, presents three different levels of information processing: skill, rule and knowledge.
If you are an experienced motorist driving along an uncomplicated road you will be operating at the skill level. Your actions will be automatic, involving little conscious effort. You change gear, accelerate and brake without thinking about the individual movements. This is the easiest mode of behaviour, and leaves time to listen to the radio or have a conversation.
When you arrive at a crossroads or a roundabout you have to apply rules. This involves more effort than the skill-based behaviour, but if you are practised in applying the rules and increase your attention level, the result should be error free.
Knowledge-based processing requires the most effort, and we usually operate at the easiest level that works for a task
If your normal route is blocked – and assuming you have no navigation aid – you have to apply knowledge, by picturing the back roads and working through which would give the best alternative route.
Knowledge-based processing requires the most effort, and we usually operate at the easiest level that works for a task. I have the skill to create words on a computer screen without thinking about the keys I hit. When something goes wrong I apply rules – I save my files and switch the computer off and on again. If that doesn’t work, I might have to ask people with more knowledge.
Disasters can occur when people don’t move to the appropriate performance level – they fail to apply their knowledge correctly, or because they have been trained to operate only at skill and rule level – they do not have the knowledge to diagnose and treat a problem. Contrast the 1989 Kegworth air crash – when it is believed the pilots shut down the wrong engine because their knowledge was based on an earlier model of the Boeing 737 plane – with the successful landing of an Airbus A320 on the Hudson River in 2009. The Airbus pilot was also a glider instructor. He applied his knowledge of unpowered aircraft to the problem of how to bring down the plane safely with engines disabled. The wider our knowledge of related subjects, the greater becomes the potential for its cross-application.
When a skill-based task goes wrong, we start with rules. The problem comes if we fail to recognise when to move to knowledge-based thinking. A factor in the meltdown at the Three Mile Island nuclear plant in the US in 1979 was that operators continued to apply a rule about an indicator light when their knowledge could have told them this was wrong. By ignoring the results of a pressure test that indicated a problem, the Deepwater Horizon disaster in 2010 showed that people will still revert to (mis)applying rules in an emergency, rather than use system knowledge.
Most fire drills are based on the rule, “if the bell rings, go out this door, down these stairs to this location”. But what if the fire exit is blocked, or there is a bomb threat, or a marauding gunman is in the building? In this case, staff may have the knowledge on which to make alternative decisions – they probably know other routes out of the building – but they should not be relied upon to improvise under pressure. For fire drills and other operations where we want people to use knowledge rather than over-rely on rules, we need to simulate a variety of emergencies and abnormal conditions and practice different scenarios.
So the next time you see “competence” in a risk assessment as a hazard control, consider whether this is skill, rule or knowledge-based, and check that training and experience meets that need.