Human Factors Masterclasses Matt Lindley Human Factors Training Consultant

I have had the luxury of Crew Resource Management / Human Factors imbedded in aviation culture through out my career.  As a result human fallibility, assertiveness and flatter authority gradients have been a part of the working environment for my entire flying career.

I recall on one routine flight, I was manually flying the aircraft (no auto pilot) as the co pilot.  I selected the under carriage down.  About one minute before landing, an automatic system warned us that the wheels were not in the down and locked position. The Captain checked cockpit secondary indications that showed the wheels were in the correct position and it seemed that the warning was spurious.  The Captain announced 'continue' (to land). Since I was hand flying the aircraft my spare capacity to cross check this vital information was limited.  About 20 seconds before landing, a second warning rung out that the wheel were not deployed, the Captain announced again 'continue' but my inability to cross check due to work load made me feel very uncomfortable and instead I elected to fly a low level go round and launched the aircraft back into the air, contrary to the Captains decision.  With hindsight the Captain's decision to continue was entirely correct but my inability to process further information at a critical stage of flight made me feel very uneasy.

Human factors awareness allowed us both to appreciate I was approaching overload, I was empowered by the organisations culture to assert myself when safety was compromised.  The Captain understood my decision to fly a go around instead of landing, he praised my actions and we conducted a full debrief afterwards. Because the Captain had also undergone the same non technical training as myself, I walked away not worrying about undermining him, instead he empowered me and reinforced the importance graded assertiveness when safety may be compromised.

When I was asked to join the Atrainability team I was surprised how different the culture in healthcare was. The challenge of culture change in any organisation, though not always easy, is hugely rewarding when delegates have a 'light bulb' moment. Recently I was teaching FY2 Doctors a module on situation awareness and cognitive overload. One Doctor shared a recent experience involving a drug error within the ward.  Whilst in a demanding high work load environment,  the Doctor had been asked to cross check a drug.  In the aftermath of the incident she was asked to recalled checking the dosage but had no recollection of hearing or consciously reading the prescription.  During the module we discussed how information is processed in our brain when working in an 'overload' situation and how our hearing is the first of the senses to shut down when we are saturated with information. She shared with the group her experience and was pleased to understand why her hearing and recollection of the cross check was limited. 

A general awareness of our own limitations allows professionals who, work in high risk environments, reduce their exposure to error.

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