- Having the proper information at hand and,
- being able to make the proper decision based on that information.
"A decision is thus no better than the information it is based on."
Could Chalk Airlines accident (N2969 killing all 20 people aboard) been prevented if better information were present? How many times have mechanics found the manufacturer's service department is "non- existent" or provides little information? Is the method of delivering critical information to the mechanic effective? "It's up to the mechanic" attitude toward service information doesn't lead to an effective solution nor enhance safety. Many times this is an organizational problem and responsibility.
Chalk Airlines mechanic's decisions, while with hindsight are fatally flawed, might not have been an incorrect decision based on the information present at the time. Throw in a dose of confirmation bias and the decision even becomes expected under the circumstances. This leads one to the conclusion that accidents such as this one are not a one-off event.
2. Being able to make the proper decision based on that information
Confirmation Bias recognition and management
We can have a lively discussion about what decision to make even when all relevant information is present. I don't understand why you don't agree with me and you don't understand why I don't agree with you. "People believe what they want to believe" This is Confirmation Bias. Interesting accidents caused by Confirmation Bias include Comair Flight 5191, Airbus A321-232 SK-473 and Airbus A320 UP-BWM. A more formal description of Confirmation Bias:
Confirmation bias is a phenomenon wherein decision makers have been shown to actively seek out and assign more weight to evidence that confirms their hypothesis, and ignore or underweight evidence that could disconfirm their hypothesis. As such, it can be thought of as a form of selection bias in collecting evidence.
We all have Confirmation Bias. It's not a defect but normal human behavior. Errors caused by Confirmation Bias are not solved through penalties. For the aircraft mechanic I believe there are two methods of reducing maintenance errors caused by Confirmation Bias:
- You cannot inspect your own work. Often you cannot see your own mistakes, even glaring ones, because your mind has already decided that the work was done as you intended. An inspector does not have your bias (he has his own) and can better judge your work.1.
- Education and recognizing when Confirmation Bias might be present.
Part II Irrational Positive Bias in Aircraft Maintenance
Further Reading:
Metal Fatigue, Cracks, and Turbo Mallards
Cracks in Aircraft Structures
Notes:
1. Who made the mistake? The mechanic who didn't do the job properly? The inspector who failed to notice the mistake? or the employer who failed to provide an inspector?
Confirmation Bias in Reading |
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