A fascinating book on airplane crashes reveals a chilling pattern: disaster after disaster, and huge losses of life, were ultimately caused by poor decision-making. What’s striking is the similarity to so many coronial inquests for outdoor education incidents.
Much like fatalities on outdoor expeditions, each of the airplane disasters could have been avoided. However, fatigue and poor decision-making created a fatal combination.
So why are we so impaired by fatigue, and why do some organisations still fail to see this as a major problem?
The Science of a Fatigued Brain: Why Good People Make Bad Decisions
When we’re fatigued, a cascade of cognitive failures begins which reduces our ability to make clear, informed, and reasonable decisions. The harder we try, the less effective this becomes.
- Tunnel Vision: Our focus narrows, crippling our ability to see the bigger picture and make sound, reasoned judgments. Experienced pilots forget their training. Simple corrective actions aren’t taken.
- Impaired Problem-Solving: Our ability to solve complex problems is significantly inhibited. Even regular, simple tasks become compromised.
- Obsession with Irrelevance: Fatigued individuals often focus on something completely irrelevant to the problem at hand. They can obsess over a minor detail, believing it's the key to solving their current problem, unable to rationalise that their focus is completely pointless.
Research has shown that not sleeping for 24 hours (which includes poor or broken sleep) has the same effect on decision-making as being drunk. We would never allow teachers and instructors to be drunk at work. So why do we allow fatigue to be so dangerously overlooked?
From the Cockpit to the Trail: How Fatigue Leads to Disaster
The cockpit recordings from plane crashes make the consequences of fatigue abundantly clear. In one example, despite all evidence suggesting the pilots needed to push down on the controls to increase speed and prevent a stall, they kept pulling back on the stick, condemning the plane and everyone onboard. Before we call them stupid the temptation of a back-seat pilot with no airtime we must understand the profound effects of fatigue.
Unfortunately, in outdoor education, we rarely have firsthand recordings of events as they transpire. But when you compare the "black box" evidence from the airline industry with coronial inquests into outdoor education fatalities, you can see how fatigue likely impaired judgment, triggering the repeatedly poor decisions that led to a fatality.
Good decision-making is one of the best risk management strategies you can have. A good leader continually assesses a situation, adapts, and responds accordingly. Most of the time, their corrective actions are so smooth they aren’t even noticeable. But when we’re fatigued, that vitally important, broad problem-solving skill set stops working.
A Dangerous Culture: Why "Pushing Through" Is Not a Strategy
The only solution for fatigue is sleep. It’s not to "push through it," as a former boss of mine would always profess. One school I worked for was vehemently opposed to any discussion around fatigue, despite staff raising numerous concerns about well-being. The implication was that we were lazy. I would suggest that working 80+ hour weeks, backed up by driving vehicles full of students, was a pre-loaded disaster waiting to happen.
This mindset—that fatigue is a weakness to be overcome by toughness—is not just wrong; it’s idiotic in the extreme and will eventually result in someone getting killed. You can always learn a lot from idiots; they demonstrate the dangers of what not to do.
The Solution: Building a Robust Fatigue Management System
Not all outdoor ed fatalities have fatigue as a contributing factor. But if we’re aware that it’s one of the most dangerous problems we face, we can put systems in place to manage it.
The outcome of the airplane crash investigations was that systems to monitor and address fatigue were introduced, resulting in safer air travel. For outdoor education, this is something that must be addressed now. It can’t be ignored or put off for a later discussion.
Ask yourself these questions about your own programs:
- How long is an acceptable shift for your staff?
- What are the tasks required during this time, and what is the cognitive load?
- What driving is involved, and can that load be shared?
- What is the process if a staff member reports feeling fatigued?
- What backup plans are in place?
The fatal vehicle accident in New Zealand, where a teacher fell asleep at the wheel, is self-evident proof that fatigue and good decision-making don’t mix.
Do you have a fatigue management system in place? If not, make it your number one priority today. It is vital that we keep safe those for whom we’re responsible, and that starts with ensuring our instructors have clear heads and sharp decision-making skills.
