A behavioral intervention for reducing post-completion errors in a safety-critical system

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McDonald, Joseph Douglas
Durso, Frank
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A widespread and persistent memory error that people commit on a daily basis is the post-completion error (PCE; i.e., forgetting to complete the final step of a procedural task). PCEs occur in the railroad industry when a locomotive conductor changes the direction of a rail switch but fails to report this change. This particular error could contribute to unsafe conditions as another train traveling on the same track could derail. Although training can help reduce some of the factors leading to unsafe conditions on the rail, research has demonstrated that PCEs are different from other errors of omission in that they cannot be eliminated through training, which makes them a difficult problem to address. Therefore, there is a need to explore new remedial actions designed to reduce PCEs. The current study investigated the effectiveness of a theoretically motivated intervention at reducing PCEs in trainyard operations, where making these errors could be life-threatening. Twenty-eight undergraduates completed trainyard tasks within a high-fidelity simulator. Each participant received the behavioral intervention in one block and no intervention in another. Specifically, participants were required to perform an additional task designed to remind participants of the post-completion (PC) step. The intervention significantly reduced PCE rates in the context of trainyard operations, on average, by 65%. We discuss implications of these results on reducing trainyard accidents, and how this outcome can contribute to the literature on the cause of PCEs.
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