progress with foresight regress with hindsight 18 th national conference rural public and intercity...

Progress with ForesightProgress with ForesightRegress with HindsightRegress with Hindsight

18th National Conference Rural Public and Intercity Bus

Transportation

Omaha, Nebraska ~ October 19-22, 2008Omaha, Nebraska ~ October 19-22, 2008

Michael DilichMichael DilichVice President, Director of ResearchVice President, Director of Research

FORESIGHTFORESIGHT reconstruction, inc. reconstruction, inc.

Morton Grove, IllinoisMorton Grove, Illinois• Education: Mechanical Engineering, IL Institute of Tech - 1966• Investigation, Reconstruction and Analysis of major loss

accidents involving commercial and private vehicles - 1982• FHA Commercial Vehicle Preventable Accident Manual - 1991• Applied Research since 2000: - Driver behavior during sudden emergencies.

- Foreseeability of harm in transportation accidents. - Judgmental biases in causal analysis of accidents.

““Those who know Those who know how things turned out how things turned out have trouble believing have trouble believing others didn’t see others didn’t see what was coming.” what was coming.”

Baruch Fischhoff, 1975Baruch Fischhoff, 1975

Hindsight: Thinking BackwardHindsight: Thinking Backward Dr. Baruch Fischhoff Dr. Baruch Fischhoff

19751975

““The Hindsight Bias”The Hindsight Bias”

andand

the 1814 war between the 1814 war between

The British and the Gurkas of NepalThe British and the Gurkas of Nepal

5 groups of test subjects5 groups of test subjects1 1 foresightforesight group & 4 group & 4 hindsighthindsight groups groups

1.1. Foresight GroupForesight Group not told how the war ended. not told how the war ended.

2.2. Hindsight GroupHindsight Group told war ended in a military stalemate told war ended in a military stalemate with a peace treaty.with a peace treaty.

3.3. Hindsight GroupHindsight Group told war ended in a military stalemate told war ended in a military stalemate without a peace treaty.without a peace treaty.

4.4. Hindsight GroupHindsight Group told war ended with a told war ended with a British victoryBritish victory..

5.5. Hindsight GroupHindsight Group told war ended with a Gurka victory told war ended with a Gurka victory..

For some years after the arrival of Hastings as governor-general of For some years after the arrival of Hastings as governor-general of India, the consolidation of British power involved serious wars. India, the consolidation of British power involved serious wars. The first of these wars took place on the northern frontier of The first of these wars took place on the northern frontier of Bengal where the British were faced with the plundering raids of Bengal where the British were faced with the plundering raids of the Gurkas of Nepal. Attempts had been made to stop the raids by the Gurkas of Nepal. Attempts had been made to stop the raids by an exchange of lands, but the Gurkas would not give up their an exchange of lands, but the Gurkas would not give up their claims to land under British control, and Hastings decided to deal claims to land under British control, and Hastings decided to deal with them once and for all. The campaign began in November, with them once and for all. The campaign began in November, 1814. It was not glorious. The Gurkas were only some 12,000 1814. It was not glorious. The Gurkas were only some 12,000 strong: but they were brave fighters, fighting in territory well-strong: but they were brave fighters, fighting in territory well-suited to their raiding tactics. The older British commandeers suited to their raiding tactics. The older British commandeers were used to war in the plains where the enemy ran away from a were used to war in the plains where the enemy ran away from a resolute attack. In the mountains of Nepal it was not easy even to resolute attack. In the mountains of Nepal it was not easy even to find the enemy. The troops and transport animals suffered from find the enemy. The troops and transport animals suffered from the extremes of heat and cold, and the officers learned caution the extremes of heat and cold, and the officers learned caution only after sharp reverses. Major-General Sir D. Ochterlony was only after sharp reverses. Major-General Sir D. Ochterlony was the one commander to escape from these minor defeats.the one commander to escape from these minor defeats.

For some years after the arrival of Hastings as governor-general of For some years after the arrival of Hastings as governor-general of India, the consolidation of British power involved serious wars. India, the consolidation of British power involved serious wars. The first of these wars took place on the northern frontier of The first of these wars took place on the northern frontier of Bengal where the British were faced with the plundering raids of Bengal where the British were faced with the plundering raids of the Gurkas of Nepal. Attempts had been made to stop the raids by the Gurkas of Nepal. Attempts had been made to stop the raids by an exchange of lands, but the Gurkas would not give up their an exchange of lands, but the Gurkas would not give up their claims to land under British control, and claims to land under British control, and Hastings decided to deal Hastings decided to deal with them once and for allwith them once and for all. The campaign began in November, . The campaign began in November, 1814. It was 1814. It was not gloriousnot glorious. The Gurkas were only some . The Gurkas were only some 12,000 12,000 strongstrong: but they were : but they were brave fightersbrave fighters, fighting in , fighting in territory well-territory well-suited to their raiding tacticssuited to their raiding tactics. The . The older British commandeers older British commandeers were were used to war in the plains used to war in the plains where the enemy ran away from a where the enemy ran away from a resolute attack. resolute attack. In the mountains In the mountains of Nepal it was of Nepal it was not easy even to not easy even to find the enemyfind the enemy. The troops and transport animals suffered from . The troops and transport animals suffered from the the extremes of heat and coldextremes of heat and cold, and the , and the officers learned caution officers learned caution only after sharp reversesonly after sharp reverses. Major-General Sir D. Ochterlony was . Major-General Sir D. Ochterlony was the one commander to escape from these minor defeatsthe one commander to escape from these minor defeats..

Knowing that something had happenedKnowing that something had happenedroughly doubled the perceived odds thatroughly doubled the perceived odds thatit was going to occur.it was going to occur.

AnchoringAnchoring

Fischhoff found that hindsight bias Fischhoff found that hindsight bias is not deliberate. His test subjects had is not deliberate. His test subjects had no vested interest in the outcome of his no vested interest in the outcome of his test.test.

FISCHHOFF’S CONCLUSIONFISCHHOFF’S CONCLUSION

Finding out that something happened increases itsFinding out that something happened increases itsperceived inevitability.perceived inevitability.

We are unaware of this effect of outcomeWe are unaware of this effect of outcomeknowledge and believe that the inevitability was knowledge and believe that the inevitability was largely apparent in foresight, without the benefitlargely apparent in foresight, without the benefitof knowing what happened.of knowing what happened.

thusthus

The Hindsight BiasThe Hindsight Bias

““Those who know Those who know how things turned out how things turned out have trouble believing have trouble believing others didn’t see others didn’t see what was coming.” what was coming.”

Baruch Fischhoff, 1975Baruch Fischhoff, 1975

““The Knew It All Along Effect”The Knew It All Along Effect”

““Magical ThinkingMagical Thinking””

H. Bursztajn, et al., 1988H. Bursztajn, et al., 1988Harvard Medical SchoolHarvard Medical SchoolAmerican Academy of Psychiatry & the LawAmerican Academy of Psychiatry & the Law

Illusion of ForeseeabilityIllusion of Foreseeabilityversusversus

True ForeseeabilityTrue Foreseeability

Mike Dilich, 2008

****WARNING********WARNING****

Hindsight bias is hard to recognize and hard Hindsight bias is hard to recognize and hard to “feel” it happening. Since it is natural for to “feel” it happening. Since it is natural for people to use outcome knowledge when people to use outcome knowledge when looking at the past, people may react with looking at the past, people may react with puzzlement to concerns about this bias and puzzlement to concerns about this bias and falsely believe that they are immune to its falsely believe that they are immune to its influence.influence.

ProfessionProfessionEducationEducationIntellectIntellectRaceRaceGenderGender

JudgesJudgesLawyersLawyersScientistsScientistsEngineersEngineersPsychologistsPsychologists

Hindsight bias is like an optical illusion,Hindsight bias is like an optical illusion,

it deceives our perceptions and it deceives our perceptions and fools us all. fools us all.

None are immune!None are immune!

HINDSIGHT: HINDSIGHT: perception of the perception of the significance and nature of events significance and nature of events afterafter they have occurred. they have occurred.

Current dictionary definitions:Current dictionary definitions:

FORESIGHT: FORESIGHT: perception of the perception of the significance and nature of events significance and nature of events beforebefore they have occurred. they have occurred.

HindsightHindsight is concerned with a is concerned with a certain past.certain past.

ForesightForesight is concerned with an is concerned with an uncertain future.uncertain future.

HindsightHindsight involves explanation of involves explanation of one outcome …… one outcome …… the one that actually occurred. the one that actually occurred.

ForesightForesight involves consideration of involves consideration of many possible outcomes.many possible outcomes.

HindsightHindsight and and ForesightForesight

differ in regards to the information differ in regards to the information

available to the observer:available to the observer:

The The hindsightfulhindsightful observer knows what happened. observer knows what happened.

The The foresightfulforesightful observer does not. observer does not.

Hindsight Hindsight is cheap and easy. is cheap and easy. We all partake in hindsight routinely We all partake in hindsight routinely and we’re all good at it. and we’re all good at it. It’s easy to be wise after-the-fact.It’s easy to be wise after-the-fact.

Foresight Foresight is expensive. is expensive. People with good foresight are valuable. People with good foresight are valuable. Foresightful people sense what’s coming Foresightful people sense what’s coming and prepare for it.and prepare for it.

Does sharper hindsight Does sharper hindsight improve our foresight?improve our foresight?

DDoes history teach us lessons oes history teach us lessons that will improve our future?that will improve our future?

““Historians begin by Historians begin by looking backwardlooking backward..They often end by They often end by thinking backwardthinking backward.”.”

Friedrich Wilhelm Nietzsche, 1800’s

What was the chance of rain yesterday?What was the chance of rain yesterday?

An example of recent history…the weather

Predicting the WeatherPredicting the Weather

• Most everyday foreseeability judgments Most everyday foreseeability judgments apply to future events. apply to future events.

• Trying to foresee the Trying to foresee the chance of rain chance of rain tomorrowtomorrow makes sense and is certainly makes sense and is certainly useful.useful.

• We do it all the time.We do it all the time.

Predicting the Weather (2)Predicting the Weather (2)• But did you ever try to foresee the chance

of rain yesterday?

• It sounds senseless and certainly not very useful. Why would anyone do that?

• If it rained, it rained for sure, not with a probability of 30% or 60%.

• Even if we try, we find we’re not very good at it.

Predicting the Weather (3)Predicting the Weather (3)

• Those who were asked yesterday before it rained Those who were asked yesterday before it rained might have estimated a 30% chance of rain.might have estimated a 30% chance of rain.

• But those who now know it rained for sure, know But those who now know it rained for sure, know too much and will estimate much higher, like too much and will estimate much higher, like 60%.60%.

• That ratio of 2:1 of those That ratio of 2:1 of those with outcome knowledge with outcome knowledge to those to those without outcome knowledge without outcome knowledge is: is:

““The Hindsight Bias”The Hindsight Bias”

KatrinaKatrina

Misfortune occurs,Misfortune occurs,A potential culprit is identified,A potential culprit is identified,His decision second-guessed in His decision second-guessed in hindsighthindsight,,He is chastised for his lack of He is chastised for his lack of foresightforesight..

Pearl HarborPearl HarborSpace Shuttle ColumbiaSpace Shuttle Columbia

Three-mile Island

9/119/11Wall StreetWall Street

Dr. Richard I. CookCognitive Technologies LabsUniversity of Chicago

Hindsight analysis Hindsight analysis highlights the actual path highlights the actual path that led to the tragic outcome, that led to the tragic outcome, making the path appear so making the path appear so obviousobvious that we have trouble believing that we have trouble believing those involved didn’t see those involved didn’t see what was coming next.what was coming next.

““Those who know Those who know how things turned out how things turned out have trouble believing have trouble believing others didn’t see others didn’t see what was coming.” what was coming.”

Baruch Fischhoff, 1975Baruch Fischhoff, 1975

Dr. Richard I. CookCognitive Technologies LabsUniversity of Chicago

““The actor’s conduct must be judged The actor’s conduct must be judged in the light of the possibilities apparent in the light of the possibilities apparent to him at the time and not by looking to him at the time and not by looking backward….backward….

‘‘with wisdom born of the event’”with wisdom born of the event’”

In a negligence law:In a negligence law:

““The standard is one of The standard is one of conductconduct, rather , rather than of than of consequencesconsequences. It is not enough . It is not enough that everyone can see now that the risk that everyone can see now that the risk was great, if it was not apparent when was great, if it was not apparent when the conduct occurred.”the conduct occurred.”

Prosser and Keeton on TortsProsser and Keeton on Torts

““unfortunately unfortunately people always judge people always judge conductconduct

on its on its consequencesconsequences””

****************WARNINGWARNING ******** ********An overwhelming problem when investigating An overwhelming problem when investigating

what went wrong and who was a fault.what went wrong and who was a fault.

““In determining whether the actorIn determining whether the actorshould recognize the risks should recognize the risks which are involved in his conduct, which are involved in his conduct, either of act or omission, either of act or omission, only those circumstances only those circumstances which the actor perceives or should perceive which the actor perceives or should perceive at the time of his action or inactionat the time of his action or inaction are to be considered. are to be considered.

Restatement of Torts, SecondRestatement of Torts, SecondAmerican Law InstituteAmerican Law InstituteChapter 12, paragraph 282(h)Chapter 12, paragraph 282(h)

Circumstances which occur Circumstances which occur afterafter the conduct the conduct which is alleged to be negligent which is alleged to be negligent are as are as immaterialimmaterial as are those circumstances as are those circumstances which exist at the time of his action or inaction,which exist at the time of his action or inaction,but of which the actor neither knows but of which the actor neither knows nor should know, nor should know, although known to third persons.” although known to third persons.”

Counterfactual means literally, Counterfactual means literally, contrary to fact. Counterfactual contrary to fact. Counterfactual thoughts are thoughts of what did thoughts are thoughts of what did not not happen, but could have happened, had happen, but could have happened, had some detail or action been different.some detail or action been different.

COUNTERFACTUAL THINKINGCOUNTERFACTUAL THINKING

~ Flip a coin in the air.~ Flip a coin in the air.~ There are two possible outcomes, ~ There are two possible outcomes, heads or tails. heads or tails.~ The moment it comes to rest the possibilities~ The moment it comes to rest the possibilities vanish. vanish.~ It lands heads up.~ It lands heads up.~ With absolute certainty, heads is the outcome.~ With absolute certainty, heads is the outcome.~ Heads becomes the ~ Heads becomes the factual outcomefactual outcome..~ It could have landed tails up, but it didn’t.~ It could have landed tails up, but it didn’t.~ Tails becomes a ~ Tails becomes a counterfactual outcomecounterfactual outcome.

The outcome of a sequence of events The outcome of a sequence of events is the starting point of your work as investigator. is the starting point of your work as investigator. Otherwise you wouldn’t actually be there.Otherwise you wouldn’t actually be there.

This puts you at a This puts you at a remarkable disadvantage remarkable disadvantage when it comes to understanding the point of view when it comes to understanding the point of view of the people you’re investigating.of the people you’re investigating.

Tracing back from the outcome you will come Tracing back from the outcome you will come across joints where people had opportunities to across joints where people had opportunities to ““zig” instead of “zag” where they could have zig” instead of “zag” where they could have directed the events away from failure.directed the events away from failure.

As investigator you come out on the other end As investigator you come out on the other end of the sequence of events wondering how people of the sequence of events wondering how people could have missed those opportunities could have missed those opportunities to steer away from failure.to steer away from failure.

IMPORTANT TO NOTE!IMPORTANT TO NOTE!

For those involved, there were For those involved, there were no counterfactuals no counterfactuals

of what could have happened insteadof what could have happened instead------------------- -------------------

only possibilities of what might only possibilities of what might happen nexthappen next

As the situation As the situation is (not was) is (not was) unfolding, unfolding, the point of view of those involved the point of view of those involved

matters…matters…

……our point of view as after-event observers, our point of view as after-event observers,

with with “the wisdom born of the event” “the wisdom born of the event” is immaterial to is immaterial to the reasonableness of the conduct of those involved the reasonableness of the conduct of those involved

when the conduct occurred.when the conduct occurred.

POINT OF VIEW MATTERSPOINT OF VIEW MATTERS

Hours, Days & Years AfterHours, Days & Years AfterObserver’s Points of ViewObserver’s Points of View

Uninvolved Uninvolved Before & After-the-Fact InformationBefore & After-the-Fact Information

What HappenedWhat HappenedSingle Attentional FocusSingle Attentional Focus

Dangerous EmergencyDangerous EmergencyFatalities and/or Serious InjuriesFatalities and/or Serious Injuries

Backward LookingBackward LookingBackward ThinkingBackward Thinking

Digital AnalysisDigital AnalysisMentally Undo Accident and Try AgainMentally Undo Accident and Try Again

Precursors are ClearPrecursors are Clear

POINT OF VIEWPOINT OF VIEW

Three Seconds BeforeThree Seconds BeforeDriver’s Point of ViewDriver’s Point of ViewDirectly Involved Directly Involved Before-the-Fact InformationBefore-the-Fact InformationWhat is HappeningWhat is HappeningSeveral Attentional DemandsSeveral Attentional DemandsRoutine Traffic Flow Routine Traffic Flow No injuriesNo injuriesForward LookingForward LookingForward ThinkingForward ThinkingAnalog AnalysisAnalog AnalysisNo Second ChanceNo Second ChancePrecursors are AmbiguousPrecursors are Ambiguous

Pre-accident versus Post-accidentPre-accident versus Post-accident

The danger of hindsight bias in accident The danger of hindsight bias in accident analysis is that:analysis is that:• It is natural for people to be biased by hindsight.It is natural for people to be biased by hindsight.

• It is caused by a deeply ingrained cognitive process that It is caused by a deeply ingrained cognitive process that

cannot be easily eliminated or even moderated.cannot be easily eliminated or even moderated.

• It is not intentional or deliberate.It is not intentional or deliberate.

• It is difficult to feel it happening.It is difficult to feel it happening.

• People are not aware of it happening to them.People are not aware of it happening to them.

• It is universal, regardless of profession or intellect.It is universal, regardless of profession or intellect.

• Hindsight judgments are easier to make than foresight Hindsight judgments are easier to make than foresight

judgments.judgments.

• Hindsight involves one explanation, whereasHindsight involves one explanation, whereas

foresight considers many possible alternatives.foresight considers many possible alternatives.

• People cannot be debiased merely by warning them to People cannot be debiased merely by warning them to

guard against it.guard against it.

Most traces of causality begin with the outcome Most traces of causality begin with the outcome and trace backwards in time until they encounter a human and trace backwards in time until they encounter a human whose actions appear to be, in hindsight, inappropriate or suboptimal.whose actions appear to be, in hindsight, inappropriate or suboptimal. The dilemmas facing the practitioner in situ, The dilemmas facing the practitioner in situ, the uncertainties, trade-offs, and attentional demands the uncertainties, trade-offs, and attentional demands all may be underemphasized when an incident is viewed in hindsight.all may be underemphasized when an incident is viewed in hindsight. It was clear from their studies of large system failures that It was clear from their studies of large system failures that hindsight bias remains the greatest obstaclehindsight bias remains the greatest obstacle to evaluating to evaluating

the performance of humans in complex systemsthe performance of humans in complex systems..

David Woods, et al, 1994David Woods, et al, 1994““Behind Human Error: Cognitive Systems, Computers and Hindsight”Behind Human Error: Cognitive Systems, Computers and Hindsight”

““Knowledge of the outcome makes it Knowledge of the outcome makes it seem that events leading to the outcome seem that events leading to the outcome should have appeared more obvious than should have appeared more obvious than was actually the case.”was actually the case.”

““This outcome knowledge This outcome knowledge poisonspoisons the the ability of after accident observers to ability of after accident observers to recreate the view of the situation before recreate the view of the situation before the accident.”the accident.”

Richard Cook, 1998 Richard Cook, 1998 Cognitive Technologies LaboratoryCognitive Technologies Laboratory

““When blessed with both uninvolvement and When blessed with both uninvolvement and hindsight, there is a great temptation for hindsight, there is a great temptation for retrospective observers to slip into a retrospective observers to slip into a censorious frame of mind and to wonder at censorious frame of mind and to wonder at how people could have been so blind, stupid, how people could have been so blind, stupid, arrogant, ignorant or reckless.”arrogant, ignorant or reckless.”

James Reason on Human Error, 1990James Reason on Human Error, 1990

““Before judging too harshly the human Before judging too harshly the human failings that concatenate to cause a disaster, failings that concatenate to cause a disaster, we need to make a clear distinction between we need to make a clear distinction between the way the precursors appear nowthe way the precursors appear now, given , given knowledge of the unhappy outcome, and the knowledge of the unhappy outcome, and the way they seemed at the time”way they seemed at the time”

James Reason on Human Error, 1990

WARNINGWARNING““Unless we appreciate the potency Unless we appreciate the potency

of these retroactive distortions, of these retroactive distortions, we will never truly understand we will never truly understand

the realities of the past, the realities of the past, nor learn the appropriate nor learn the appropriate

remedial lessons.”remedial lessons.”

Reason, 1990

““Failure to appreciate the effects of Failure to appreciate the effects of outcome knowledge can outcome knowledge can seriously seriously prejudice prejudice the evaluation of decisions the evaluation of decisions made in the past and made in the past and limitlimit what is what is learned from experience.”learned from experience.”

Baruch Fischhoff, 1975Hindsight: Thinking Backward

““Before beholding the mote Before beholding the mote [the speck][the speck]

in his brother’s eye, in his brother’s eye, the retrospective observer the retrospective observer

should be aware of the beam should be aware of the beam of hindsight bias in his own!”of hindsight bias in his own!”