Unintended: A theory of TASER/weapon confusion

Originally published on the Force Science Institute website. Republished here with permission.

When an officer first learns to draw their pistol, it may require intense focus to defeat the holster’s retention features, secure a proper grip, maintain a safe orientation and efficiently draw and capture a sight picture. However, with sufficient practice, this process will be performed with little cognitive effort or awareness. This ability to draw a weapon or perform any skilled task without the need for focused attention or “cognitive control” is referred to as “automaticity.”

For police, automaticity frees up their “cognitive load” for more effective decision-making and allows them to remain externally focused on threat assessments, changing environmental conditions and communication efforts. Unfortunately, the repetitive performance that leads to automaticity can also play a role in a common performance error known as a “capture error.”

A “capture error” can occur when an infrequent action like drawing a TASER is non-consciously substituted by a similar, more familiar and more practiced action – like drawing a firearm. Research has shown that people are particularly susceptible to this type of error when they are occupied by other mental processes. For police, these processes might involve time-compressed threat assessments, the need for immediate action, or simultaneous efforts to communicate – including verbal warnings and de-escalation attempts.

These are Resilient Errors

Capture errors fall under the category of performance errors known as “slips.” Slips occur when someone has the right intention but fails in its execution (and this failure cannot be attributed to some chance intervention).

Human factors researchers have observed that slip errors can have severe consequences. They are difficult to reduce – even with training, visual cues, or increased motivation. Experts and novices are susceptible to slip errors. They are not the result of a lack of knowledge or expertise but instead occur from a temporary failure of working memory.

Efforts to reduce errors by inserting visual cues, weight disparities and audible warnings can be affected by attentional limitations. Humans perceive what they pay attention to, and during critical incidents, their attention may be involuntarily pulled to the most “salient” stimulus in the environment. Often, that is the person, object, or action perceived to pose the greatest threat.

[In your experience, how can training help mitigate the risk of TASER/weapon confusion? Submit your response in the box below.]

When a person is intently paying attention to what they perceive as a threat, it is expected that they will not perceive the other stimulus around them. That includes factors that we would expect someone to notice under calmer circumstances – factors like the weight, shape and color of a TASER as compared to a full-size firearm.

To further complicate things, human performance researchers have highlighted other processes that should be considered when looking to understand why the physical characteristics of a TASER may not always be sufficient to distinguish it from a pistol. Neuroscientist Daniel Wolpert has explained that once our brain predicts an action’s sensory consequences, we “subtract them off” and are not aware of them. Similarly, Dr. Richard Schmidt noted that once the brain concludes (even erroneously) that correct action is being executed, it can disregard feedback that might otherwise indicate you’ve selected the wrong tool or weapon.

It’s Not Just the Police: Broad Professional Interest in Performance Errors

The police are not unique in their susceptibility to performance errors. Nearly every industry involving the interaction of humans with machines has studied performance and decision-making errors. In addition to policing, the medical, engineering and aeronautical professions continue to study and build into their products and processes ways to prevent, reduce, or mitigate the consequences of errors.

The World Health Organization produced a manual that includes a chapter dedicated to the classification and prevention of common psychomotor medical errors. In response to the estimated 150,000 annual deaths caused by medical errors, doctors, pharmacists, and nurses are trained to recognize error-inducing factors and to implement error-reducing processes.

NASA has a substantial human performance section focused on engineering design and human performance training to minimize performance errors in the space program.

The aerospace industry, including Airbus, has extensively focused on airplane design and control configuration to avoid lapses, slips, and captures – three of the most common psychomotor performance errors. [1]

Those who would argue that science does not support the theory of slip errors or capture errors will need to contend with aerospace (Airbus), aeronautics (NASA), pharmaceutical, occupational safety and health, medical, industrial engineering and transportation industries.

Conclusion: Mitigating Taser/Weapon Confusion

Although extensive research has gone into understanding human error, it will never be enough to prevent them entirely. Humans will always make errors. Even so, efforts to prevent errors, interrupt errors, or mitigate the consequences of errors – including engineering and product design solutions – are often studied and implemented.

Training the mental and physical processes involved in a task, including training to maintain optimal arousal states, may also mitigate the frequency of error during critical incidents, even if they are not reasonably expected to eliminate the error.

When looking at TASER/weapon confusion cases, it bears mentioning that TASER/weapon confusion is an extremely low frequency, high consequence event. Still, it has been reported that these cases have occurred 18 times in the U.S. since 2001. We can observe in each of these cases that the officers drew the TASER with their dominant hand (the same hand an officer would routinely use to draw their firearm). This was apparently the case even when the officers conducted a cross draw.

To mitigate the risk of TASER/weapon confusion (drawing a firearm when the officer intends to draw a TASER), police professionals and TASER manufacturer Axon has recommended that officers carry the TASER on their non-dominant side. This position may prompt officers to draw and deploy the TASER with motor movements that are distinct from those required to draw and fire their pistols.

It has been suggested that the color of the TASER and the weight of the TASER can mitigate the risk of weapon confusion. However, as mentioned above, there is evidence that these factors may be insufficient to overcome the capture errors, the attentional limitations, and the suppressive cognitive processes that can occur during time-compressed critical incidents.

Although we are unaware of a documented TASER/weapon confusion incident that involved drawing the TASER with the non-dominant hand, we recognize that even this mitigation process (or vest-carrier holster option) may come with its own performance and safety trade-offs.

As the police profession considers ways to mitigate the risk of TASER/weapon confusion, the most promising solutions may be found in a holistic approach.

A better understanding of human performance under stress, more effective training, and modified equipment design and functionality are solutions extensively studied and applied in the medical and aviation industries. Policing should continue to draw on the lessons learned from these and other professions hoping to manage human error.

Bonus: Examples of Common Capture Errors

As previously mentioned, a capture error occurs when a less frequently occurring behavior is automatically substituted by a more practiced, familiar behavior. The following examples are provided for readers hoping to better understand the concept of capture errors.

Repeatedly reaching for a gear shift, ignition, or turn signal in a new or rented car only to find these controls are no longer where you expected to find them.

Even before the widespread use of TASERs, many police agencies trained and equipped officers to avoid psychomotor performance errors. Departments warned, trained and required officers to carry the same make and model handgun when on-duty and off-duty to prevent errors in the operation of the holster and weapon during stressful situations. Officers who change holsters are cautioned to practice with the new holster to reduce the likelihood of slipping back into the previous retention release and draw performance patterns. If this slip error occurs during a critical incident, officers may be unable to draw from their new holster effectively.

After transitioning from the older power brakes to the new automatic brakes, police officers in the 80s were involved in an increased number of crashes during high-speed driving because they reverted to their more familiar braking habits under stress. In doing so, the officers effectively defeated the automatic brakes’ operation and lost control of their vehicles. This error occurred despite the officers knowing the new brakes required a different manipulation.

Driving on the left side of the road in a foreign country requires additional focused attention for U.S. drivers. In anticipation of performance and decision errors, drivers new to left-side driving are warned that emergency corrective action that might work in the U.S. may be precisely the opposite of what is effective when left-side driving. During distracted or emergency circumstances involving immediate response, the most frequently practiced and executed performance can overtake (“capture”) the newer, less practiced, and more appropriate solution.

In the medical world, capture error was identified and extensively studied due to nurses incorrectly programming a new infusion pump model. Because the sequence of steps was similar but not identical to the older, more familiar pump, errors occurred. These errors were more pronounced when the nurse was distracted, in a hurry, or otherwise preoccupied.

Dr. James Reason includes the following examples of capture errors: after moving a clock from one wall in a room to another wall, automatically and repeatedly looking at the old location; continually looking in the old location after moving the location of dishes in a kitchen or tools in a workroom; automatically reaching for your keys in the pocket you most routinely store them.

Dr. Richard Schmidt, 40 years in the psychology department at UCLA and chief author of Motor learning and Performance, frequently lectured on the concepts of slip and capture errors. He gave examples and testified in court to how these errors could result in automobile accidents involving pedal misapplication errors. Pedal misapplication errors occur when a driver steps on the accelerator when intending to apply the brakes or simultaneously steps on the accelerator and the brake. A study by the National Highway Traffic Safety Administration reports that accidents involving pedal error occur approximately 16,000 times a year in the United States. Without time or attentional resources to critically analyze the problem, drivers may unintentionally push on the gas pedal (even slam on the pedal!), believing it to be the brake.

Reference

1. Reason J. Human Error. Cambridge: Cambridge University Press, 1990.

In your experience, how can training help mitigate the risk of TASER/weapon confusion? Submit your response in the box below.

Police1 readers respond

• As a former certified TASER Instructor (12 years), I always believed that there was a lack of intensity of training with the TASER. An officer would train for 4 hours per year with the TASER, whereas, depending on the jurisdiction, would receive 8 hours to 24+ hours of training with their service weapon. If the officer specializes (e.g., SWAT) in the use of weapons then that intensity is much greater. The TASER is nearly out of mind. The use of a TASER in training has to be equal or greater than the service weapon. The potential problem is that an officer may take out the TASER when they should take out their weapon, which could cost the officer their life. This is a serious problem that only training can address, but it cannot be done on the cheap. The training will have to be intense and cost cannot be diminished to lessen the needed training. Politicians are going to have to provide the funding to provide the needed training.

• Much of this can be resolved by improving the TASER. It should have an audio output every time it is removed from its holster that announces “TASER, TASER, TASER.” And this improved TASER should be incorporated into all training with it. Thus, the officer will know that a TASER is being deployed. And if they do not hear it, then they will know they are not pulling out a TASER.
• I trained and used my department-issued TASER with my nondominant hand with a cross-draw holster. I practiced every workday drawing and testing the TASER with my weak hand and only used my strong hand to remove and install the cartridge. I used a cross-draw holster due to my previous 25 years of training to protect my holstered gun.
• I have always been told to and practiced “keep your strong hand open.” To that meaning use your weak hand for everything you can and your strong hand only for what is necessary (writing, baton, shooting). Just like the old days where we were taught to hold the flashlight in the weak hand and the gun in the strong. I applied that to spray, then to the TASER. I firmly stood against the training of cross draw with a strong hand. I refused to carry that or train that way for the fear of exactly what is going on here. I set it up so the TASER would be drawn and deployed with the weak hand. The holster was turned so that was a straight draw with my weak hand just like the pistol was with my strong hand. Seriously, why would you need to deploy with your strong hand, it isn’t like you have to have a solid site picture or use both hands for it. You do what you train to do, without thinking. You grab your equipment without thinking because you train with repetitive movements. If you never use your strong hand to deploy the TASER you will never grab the wrong thing will under stress.
• I’m a right-hand shooter. My holster is on my right side. When TASERS came to our unit. I ordered a LEFT-HAND holster, no cross draw. I practiced with a training model TASER every day for weeks using my LEFT hand with my LEFT-hand holster. This worked for me. Remember muscle memory is created during training. Some actors a TASER doesn’t stop them. However, I know my RIGHT hand is free to go to my on-duty weapon in seconds.

• I propose we immediately withdraw all TASERs that were produced in the shape of a pistol. Even when brightly colored, they can be mistaken for a firearm by both the public and officers regardless of who is holding one. Require all TASERS be in the shape of a flashlight. Even allowing for “muscle memory mistakes,” it would be highly unlikely to have an officer mistake one for the other.

• In my opinion, the ONLY weapon on an officer’s duty belt that should be operated with a trigger pull is a lethal firearm. The taser should never have been designed with a trigger pull. Had the TASER been designed with a thumb-activated switch on the back of the weapon there would be no confusion. If you are pulling a trigger, you are using deadly force, period. Eliminate all other trigger pull mechanisms from any less-lethal weapons and there would be no question as to whether deadly force is being used. I realize this creates a redesign issue for TASER and re-training for officers but the benefit would outweigh the risk of another officer being involved in an accidental shooting.

• If an officer is allowed to carry a TASER, it must be in the non-dominant hand, and even worn low on the leg opposite the handgun. With 4.5 years in USMC and 31 years in law enforcement, I know to draw a weapon under stress is an automatic response. Many times the officer is not even thinking about it, it is an automatic reaction due to experience and training. Milliseconds count, and if the officer has to slow down to think, left or right hand, their life or others are at risk. Under stress, as the excellent article stated, you respond to training, not thinking. Thinking is for training, reacting automatically is for on-the-job, on-duty, survival action. This has saved me way too many times. I am lucky I never had to pull the trigger, but I attribute that to training and pre-planning. Situational awareness does slow down the action in your mind, and in that millisecond of reacting, you really do have a lot of reactionary responses going through your mind. I always taught my deputies to think of the worst-case scenario and pre-prepare. It is easier to deescalate than to escalate. Never ever stop training, or going through situations in your mind.

• I am old school and generally use my hands first, that is to grab, pull, strike or kick if warranted (and I’m not into martial arts). I think we need to retrain officers to think this way as a first reaction. Obviously, if faced with a deadly threat our firearm should be first. The TASER, and I’ve carried one for years, should be a secondary thought, not a first thought where speed and accuracy are important. If we teach officers to NOT rely first on the TASER and rely first on their hands and ability to react with physical skills first and the TASER as a second option (conscious thought must be present, not reactive) we will mitigate circumstances that occurred in Minnesota.

• I have discussed this issue before this tragic incident occurred. I am researching incorporating some type of training on the firearms range to transition between the TASER and sidearm. I remember back in the early 1990s Safariland recommended drawing the weapon 1500-2000 times before carrying the retention holster on duty. I have seen no formal training on ranges between transitioning with less lethal and lethal weapons. The tools on the officers’ belt must be incorporated into firearm exercises. We practice reload drills for the same reasons as we practice drawing – to be efficient. These incidents are occurring because of a lack of training. I have seen numerous videos of multiple officers dealing with a suspect with a knife where officers seem to all draw their firearms and there are no commands to other officers to utilize commands for less lethal. Training is needed with multiple officer and suspect encounters. I would like to be informed of any type of suggestions to implement onto a firearms course.

• It is crucial that TASER deployment and mounting on the belt be located to standardize non-dominant hand deployment. It takes practice for proper grip and aiming, but it is vital under stress due to muscle memory. Likewise, I still see cops wear and deploy handcuffs and intermediate weapons from their dominant handgun side. As a former instructor, I allowed students to use the dominant hand to deploy intermediate weapons if they so choose, as strength and aim are critical. However, I discouraged any handcuff wear on the dominant side or center back! When applying handcuffs, you need your dominant hand free to maintain suspect control, push off/strike/or takedown if needed, or transition to a weapon when only one cuff or none are secured. Center back wear of a cuff is a back injury for an officer or cuff drop just waiting to eventually happen! With any LE tool or weapon = position for performance, practice for precision, deploy with dominance.

• We moved all TASERs to a weak hand draw in 2012 and conduct scenario training annually with stress and non-stress scenarios involving the TASER during TASER recertifications.

• Additional practice outside of department-mandated training will help prevent reaching for the wrong tool. Most officers do not practice with their tools, all of them, at home. Familiarity and proficiency with all the tools and weapons we carry are as vital as physical fitness and tactics. Since we are held to a high standard and under intense scrutiny, personal responsibility for our proficiency is more important than ever before. Study and practice during an officer’s own time will make the difference.

• I carried the TASER in the S.O.Tech holster that secures the TASER with a Velcro flap and fastex buckle. It was carried on the weak hand side. Drawing the TASER is totally different than the standard firearm holster. I really liked how it protected the TASER and was able to have a quick draw with it. The holster is used by the LAPD/LASD. It might be something for police departments to think about to avoid this happening in the future. The draw from the S.O Tech holster is so different from a pistol holster that to confuse the two would be next to impossible.

NEXT: 3 recommendations to mitigate TASER/firearm “capture” errors

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