Decision Making & Fatigue Don’t Mix
Fatigue and poor decision making ultimately led to disaster
Posted on 24.10.2019
Recently, I was reading a fascinating book about airplane crashes and how poor decision making ultimately led to disaster. What was striking was the similarity to many coronial inquests for outdoor education incidents. Like many fatalities on outdoor expeditions, each of the airplane disasters could’ve been avoided.
However, fatigue and poor decision making ultimately led to disaster.
So why are we so impaired by fatigue? 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. Instead of clear, thoughtful and decisive action, mistake after mistake was made, culminating in the inevitable plane crash. Experienced pilots forgot their training and simple corrective actions weren’t taken.
The same is true of many fatalities in outdoor education. Fatigue adversely impacts the ability of a teacher to make reasoned, informed decisions. Research has shown that multiple shifts of work and not sleeping for 24 hours (which includes poor/broken sleep), has the same effect on decision making that being drunk has. Do we ever allow teachers to be drunk at work? No! So why do we allow fatigue to be overlooked?
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-simple tasks becomes compromised. The only solution for fatigue, is sleep!
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. 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. Ultimately, diminished capacity invariably leads to bad outcomes.
Unfortunately, in outdoor ed incidents, we generally don’t have first hand recordings of events as they transpire. However, in many inquests, you can see how fatigue could have impaired judgment and contributed to repeated poor decisions and the downward spiral of events which ultimately resulted in the fatality.
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 teachers, then we can put systems in place to manage and avoid fatigue and its related hazards. If we don’t want staff to be working ‘drunk’ from fatigue, we must ask. 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?
For outdoor education, this is critical. Fatigue can’t be pushed through. It can’t be ignored. It can’t be put off for a ‘later’ discussion. The end result, 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, as it’s vital that our industry keep safe those for whom we’re responsible. It’s essential to have teachers with clear heads and great decision-making skills, so that every outdoor experience is a wonderful and rewarding one for all.
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