Fixation errors occur when one focuses only on one factor rather than other equally relevant and more predictable ones. Training through simulation increases awareness of potential problems in routine and non-routine settings and allows faster skill acquisition, recognition of problems and consequently reducing human error.
Eastern Airlines Flight 401
A warm late December evening in Miami awaited the 164 passengers who travelled on Eastern Airlines flight 401from New York to Florida. The airliner was approaching Miami International Airport at approximately midnight, when the nose landing gear indicator did not illuminate when the Pilot put the landing gear down. The pilots had to identify whether the landing gear had indeed failed to extend, or more likely, if the indicator bulb in the cockpit had simply burned out; and it was of course the latter.
Approximately 30 passengers and crew miraculously survived, over 101 passengers and crew members died in the fiery crash. Investigators were puzzled to subsequently discover that apart from one burned out bulb; there was nothing wrong with the wide-bodied airliner. Unfortunately, the aircraft’s crew had becomes so fixated on trouble-shooting a burned out warning light that they do not notice their fatal descent into the terrain.
There is no easy solution to reduce the human error of fixation, but awareness of the phenomenon can help us to recognise it in ourselves and others when it occurs, so that when an emergency happens we can try to remind ourselves to remember to keep looking for alternative solutions.
Fixation causes all cognitive capacity to be focused on one task. If this task is something other than flying the aircraft, then the potential for an accident rises exponentially. Fixation is not just a single pilot issue, but can also befall entire crews as demonstrated in the case study of Eastern Air Lines flight 401.
Loss of Situational Awareness
The implications from this story for leaders of companies are clear – Fixation error can cause organizations and their employees to lose situational awareness by over focus on one task or goal (e.g. revenue growth, acquisitions), while ignoring the warning signs from other parts of the organization (e.g. safety concerns, regulatory issues). Particularly when stress levels are high.
How do you ensure that your company’s warning system is deployed appropriately? Error Prevention Institute’s AESOP method is the answer. It is a tool to identify traps such as Fixation and take corrective action to reduce human error.Best of all, our Safety Training can quickly scale from small teams and departments to the entire organization including contractors.
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