New Arctic Air Crash Aftermath Role-Play Simulation™: Orchestrating a Fundamental Surprise

• Published in: Proceedings of the Human Factors and Ergonomics Society Annual Meeting
• Main Authors: Patterson, Emily S., Woods, David D., Cook, Richard I., Render, Marta L.
• Format: Article in Journal/Newspaper
• Language: English
• Published: SAGE Publications 2001
• Subjects: General Medicine; General Chemistry; Arctic
• Online Access: http://dx.doi.org/10.1177/154193120104500422; http://journals.sagepub.com/doi/pdf/10.1177/154193120104500422

We describe an aviation scenario-based role-play simulation used to teach healthcare practitioners about barriers to learning from accidents. Participants searched for the causes of the crash in a scenario that encouraged a “garden path” explanation that the root cause was a risky decision to take off despite visible ice on the wings. During a debriefing session, the actual structure of how the system failed is revealed, including over 100 active and latent contributors to the failure with a multitude of potential lessons to improve safety. The dissonance between lessons learned during the role-play and the potential lessons creates a “fundamental surprise” situation that allows oversimplified assumptions of how complex systems fail to be challenged.