Saturday, August 7, 2010

Tenerife Airport Disaster and Bridge Resource Management

Bridge Simulator USMMA Photo

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.


My post: 40 second Boyd here

My post about the Tenerife incident here


Mario Vittone said...

We have to keep in mind the mindset that helps create (damn near forces really) those incorrect mental models. It was precisely Van Zanten's experience that created the model. "I'm the best pilot in the airline...I've never had a mishap...I know what I'm doing." All of these lessons from the past create the illusion of infallibility in pilots (and boat skippers, and surgeons, and..)

Consciously maintain the perspective that you could absolutely be wrong in any given moment is vital to effective CRM/BRM. If Van Zanten would have created the culture in his cockpit that "I could be wrong - back me up." His first officer would have said what he meant. "You're nuts! We're not going anywhere. We don't have tower clearance." Dimes to donuts Van Zanten would have heard that new mental model loud and clear.

Question for Captains: Does your first mate feel comfortable telling you, "I think you are screwing up here, Cap."? They should.

Ken E Beck said...

Mario Vittone -

Great comment. Thanks.

Barista Uno said...

I've been interested for a long time in full-mission bridge simulators, which are becoming more and more sophisticated in terms of visual realism and such.

Being no seafarer, I now wonder how much impact simulator training can have on helping ship officers avoid what you call "incorrect mental models." I've heard some ship officers derisively refer to navigational simulators as "toy ships" - implying that they can never replicate the actual operational environment on real ships.

Ken E Beck said...

Barista Uno

That's a good question. I think simulators can be a valuable tool provided certain conditions are meet. One important factor is the quality and the credibility of the instructor.

I don't think it is necessary to replicate conditions at sea, in fact you it would be unduly confusing. Real life lessons are difficult because of the sea clutter so to speak.

Perhaps these mariners you speak of are the same people who refuse to read fiction because it is not true. I think good fiction can be more true the non-fiction because the non-essential elements to the narrative are stripped away. This is what happens when we try to convey a lesson by telling a sea story. We leave out confusing facts and embellish the elements we think are important.

Mario Vittone said...

In my experience - the people who don't like "simulated" training dislike it because it forces them to be exposed to situations they have never experienced in there time at sea (or in the air). They get tested in ways they never have and that can be disconcerting.

You cannot practice a complete loss of hydraulics in the air (or complete steering loss in the port of New York) for real. But in the simulator you can play these scenarios out to thier conclusion, win or lose (live or die, set anchor or drift into oncoming vessels.)

Salty officers don't like to fail. Simulators make it possible to safely throw in "worse case." "Toy Ships" is code for "that thing scares me."

Ken E Beck said...

Mario Vittone

I think that is likely correct, the old salts don't like to fail, and not in front of the others. Good point. My idea of the fiction / non-fiction fall into the "interesting idea" category.

Barista Uno said...

It's the ego, therefore. The ego as obstacle to new ways of thinking and looking at things. Somebody should propound on this theory and come up with something as interesting and useful as gestalt psychology.

Mario Vittone said...

Read "Mistakes Were Made: But Not By Me" by Carol Tavris and Elliot Aronson

ISBN-10: 0156033909

Very useful -