Sunday, August 29, 2010
Review of "Sway The Irresistible Pull of Irrational Behavior
I picked up Sway The Irresistible Pull of Irrational Behavior when I was passing thought the airport a couple of trips ago. Mario Vittone reviews it here at Weekly Leader, another short review here.
Sway is a good read, and a good introduction to the subject of cognitive biases. which I have not given much thought to before. A couple of the examples used were the Tenerife airport disaster and the Mount Everest Disaster which was the subject of Jon Krakauer's book Into Thin Air.
If you have ever had a "what was I thinking" moment after an incident or near incident it is likely you have been the victim of cognitive bias. If you have to make operational decisions, understanding how to avoid bias could be critical.
K.C.
Saturday, August 7, 2010
Tenerife Airport Disaster and Bridge Resource Management
Continuing from my last post about Mario Vitton's post - Experience Means Nothing - Judgment is Everything. , regarding the Tenerife airport disaster . Mario writes:
With decades of experience and training telling him “no,” Van Zanten’s judgment failed him (and 582 others) and he made a mistake a rookie wouldn’t have dared to; why?That's right of course, Van Zanten's judgment did fail him. Looking at it another way however Van Zanten's mental model was wrong.
Capt Van Zanten couldn't see the runway because of fog but in his mental model, the runway was clear. When the second officer questioned that model, saying "is he not clear that Pan American" - this was a mismatch. In this case Capt. Van Zanten choose to reject the feedback. as inaccurate. Air safety research based upon this incident points to the hierarchical nature of the decision making used by flight crew as a factor in the accident.
Today, decision making among flight crews has been made more robust by the introduction of Cockpit Resource Management (CRM) . Basically CRM (and it's close cousin Bridge Resource Management or BRM) stress the importance of teamwork. Pilots must now place more weight upon the mismatch among the mental models of other team members.
Another way to say this is - before taking off in the fog make sure everyone is on the same page.
K.C.
My post: 40 second Boyd here
My post about the Tenerife incident here
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