Recently, I was reading a fascinating book about airplane crashes and how poor decision making ultimately led to disaster and the huge loss of life. What was striking about this was the similarity to so many coronial inquests for outdoor education incidents.
Much like many fatalities on outdoor expeditions, each of the airplane disasters could have been avoided. However, fatigue and poor decision making ultimately led to disaster. So why are we so impaired by fatigue and why do some organisations still not see this as a major problem?
One school, which shall remain unnamed, for which I worked a number of years ago, were vehemently opposed to any discussion around fatigue, despite numerous concerns being raised by staff around the impact it was having on the welfare and well-being of the staff. The implication was that we were just being lazy and trying to get out of work. I would suggest 80+ hour weeks backed up by driving vehicles full of students was a bit over the top. However, I’m not going to dwell on the rest of that experience, other than to say it was a pre-loaded disaster waiting to happen.
When we’re fatigued, a number of things happen which reduce our ability to make clear, informed and reasonable decisions. The harder we try, the less effective this becomes. Our focus narrows further and further into a tunnel vision that cripples our ability to make sound, reasoned judgment. This was evident in the cockpit recordings of each of the plane crashes outlined in the book. Instead of clear, thoughtful and decisive action, mistake, after mistake, after mistake was made, culminating in the inevitable plane crash. Experienced pilots forgot their training. Simple corrective actions weren’t taken.
The same is true of fatalities in outdoor education in which fatigue adversely impacts on the ability of an instructor to make reasonable, informed decisions. Research has shown that multiple shifts of work and not sleeping for 24 hours (which counts poor/broken sleep within the mix), has the same effect on decision making that being drunk has. Do we ever allow teachers and instructors to be drunk at work? No! So why do we allow fatigue to be overlooked?
If you examine the black box flight recordings of the conversations inside the cockpit, it becomes abundantly clear that for example, despite evidence to suggest that all the pilots needed to do to save the plane and those they were responsible for was to push down on the controls to increase speed and prevent a stall, they kept pulling back on the stick, consequently condemning the plane and all onboard.
However, before we call them stupid, which is the temptation of a back-seat pilot with no airtime, let’s look at the effects which fatigue has on people and why it’s not surprising that such poor decisions were made in the air and also in the field, for so many expeditions which have gone disastrously wrong.
When people are fatigued and/or drunk, their reaction time slows, their ability to solve complex problems is significantly inhibited and their ability to perform even the most regular and simple tasks becomes compromised.
The only solution for fatigue, is sleep, not push through it as a former boss of mine would always profess was the way he always did it and we should do the same! That, in my opinion, is idiotic in the extreme and will eventually result in someone getting killed. However, you can always learn a lot from idiots as they demonstrate the dangers of what not to do. Often this can be even more beneficial than someone telling you what you should do.
Good decision making is one of the best risk management strategies you can have. You see something that hasn’t gone to plan, doesn’t fit or doesn’t feel right. You assess the problem, adapt and respond accordingly. Good outdoor leaders will continually do this throughout any program. Most of the time, what they do isn’t even noticeable. Other times, it’s clear that there’s a problem and there’s a shift in plans to address it. The same is true with airlines. Most of the time you have no idea that corrective action was taken, which is the way it should be. Unfortunately, when we’re fatigued, that vitally important, broad problem-solving skill set stops working. We can only focus on single tasks and, even then, we might only be able to focus on a single part of a single task, which is even worse.
Often fatigued individuals will also focus on something that is completely irrelevant to the problem at hand. Instead, they become entrenched in a minor detail and they can obsess over it, as it’s the key to solving their current problem. However, their tired-self can’t even rationalise the fact that they’re grabbing onto something which is completely pointless, again due to their diminished capacity to make rational decisions.
Unfortunately, in outdoor ed incidents, we generally don’t have first hand recordings of the events as they transpire, which we do have for the airline industry. Listening to these recordings, it becomes clear that minor and irrelevant concerns become the sole focus of someone who is fatigued. The death spiral starts and there’s no way out. If you compare this with coronial inquests into outdoor education fatalities, on many occasions, you can see how fatigue might have impaired judgment and might have contributed to triggering the repeatedly poor decisions and the downward spiral which ultimately resulted in the fatality.
Now not all outdoor ed fatalities have fatigue as a contributing factor, but if we’re aware of the fact that it’s one of the most dangerous problems we can face even as experienced instructors, then we can put systems in place to manage and avoid fatigue and it’s related hazards. If we don’t want staff to be working ‘drunk’ from fatigue, then we must have good systems in place for managing this.
How long is an acceptable shift? What are the tasks that each staff member is doing during this time? What driving is involved? Can the load be shared? What if someone feels fatigued? What backup plans do you have in place?
The outcome of each of the airplane crashes was that systems to monitor and address fatigue were introduced, the result being, safer air travel. For outdoor education, this is something that must be addressed. It can’t be pushed through. It can’t be ignored. It can’t be put off for a discussion later in time. The end results, like the fatal vehicle accident in New Zealand where the teacher fell asleep at the wheel, are self-evident that fatigue and good decision making don’t go hand in hand. Do you have a fatigue management system in place? If not, make it your number 1 priority today as it’s vital that we and our industry ensure we keep safe those for whom we’re responsible. It’s essential to have instructors with clear heads and great decision-making skills, so that every outdoor experience is a wonderful and rewarding one for everyone.
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