5. Today’s Agenda
• We’ll take a look at some teams that are able to cope
exceptionally demanding conditions
• We’ll look at some of their underlying features and
processes
• Analysis of a team – a flight crew – that “lost it” with
disastrous consequences
• Wrap up and reflection on general lessons
6. Teams in Demanding Conditions
• High reliability organizations
Safety-critical, complex, dynamic, tightly
coupled environments
Aircraft carriers, civil aviation, nuclear power plants,
emergency responders
• Disasters
Bhopal, Tenerife air disaster, fire-fighters, Columbia Space
Shuttle
8. 8
Organization science is about
‘‘learning how to talk about
distributed interdependence
and how to hold it together’’
(Karl Weick, 2016:1)
9. Some Concepts
• “Sensemaking” - the ability to interpret and respond appropriately to
complex, ambiguous and dynamic situations - the process by which
awareness and understanding is constructed
• “Mental models” – valid, representations
of a situation shared by team members
• “Situational awareness” / “mindfulness”
• Heedful inter-relating – sensitivity to the
cues of others
• “Cue” and “frame” – we interpret cues
within a particular frame of reference
• “Losing the plot”, failing “to join up the dots”
10. 10 10
Sense-Making, Teams & Decisions
• Individuals and groups construct “mental models” which frame how they
interpret a situation and act within it – the more complex the environment, the
more sophisticated the mental models must be
• The more dynamic the environment, the greater the risk that mental models
become invalid
• In the absence of “sense”, the ability to take intelligent, appropriate is eroded;
decision-makers become confused and ignore or misinterpret crucial
information
Examples:
Starbuck and Farjoun (2005) – Foam strikes and the loss of the
Columbia space shuttle
Weick (2012) Bhopal – belief that a dangerous chemical reaction
could not happen in a plant that was shut down
12. The Accident /1
AF447 was 3.5 hours into a night flight from
Rio to Paris, cruising at 35,000ft
Three flight crew members:
• The captain (Dubois) – who left the cockpit
shortly before the episode began for a
sleep break
• The more junior first officer (Bonin) was
designated as the pilot flying (PF)
• The more senior first officer (Robert) was
in the left seat (normally the captain’s seat)
The flight approached an area of bad weather
and Bonin was anxious about this
Other flights adjusted course – AF447 did not
Climbing to avoid the storm was not an option
13. The Accident /2
Sequence of events:
• The aircraft entered a weather system
• The speed sensors (pitot tubes)
became temporarily blocked by ice
crystals, giving inconsistent airspeed
readings
• The auto pilot disconnected
• The plane went into ‘alternate law’,
removing flight envelope protections
• Error messages appeared on a display
in the cockpit (ECAM) and an aural
warning sounded
• No real crisis at this point – the crew
just had to maintain the flight path
manually
14. ECAM Messages
Robert: We’ve lost the the the speeds so…
[reading out ECAM messages]
… engine thrust A T H R engine lever
thrust … alternate law protections-
(law/low/lo1)
Bonin: Engine lever?
Robert: Watch your speed, watch your
speed
1 Robert’s words were not clear to the
transcriber, but it is likely he was in the middle of
saying “Alternate law – protections lost”. This
was crucial information about the loss of flight
envelope protection
19. Unfolding Events /1
• Bonin took manual control but caused the plane to roll left and right
• He also pulled back on his stick and the plane climbed and rapidly lost
speed
20 Seconds After Disconnection
Robert: Watch your speed, watch your speed
Bonin: Okay, okay, okay I’m going back down
Robert: Stabilise
Bonin: Yeah
Robert: Go back down. According to that we’re going up. According to all three
you’re going up so go back down
Bonin: Okay
Robert: You’re at… go back down
Bonin: It’s going, we’re going (back) down
Robert: Gently…
(13-16 seconds later the stall warning sounds and vibration and buffet begins)
20. Unfolding Events /2
• At 38,000 feet (65 seconds after auto pilot disconnection) the aircraft
stalled and began a rapid, uncontrolled descent
• But Bonin and Robert did not realize that the plane had stalled -
despite the stall warning that sounded 75 times
Direction of travel
Direction of travel
21. Unfolding Events /3
Approx 10 seconds into the stall
Robert: But we’ve got the engines, what’s happening (…)? Do you understand
what’s happening or not?
Bonin: (…) I don’t have control of the airplane any more now. I don’t have
control of the airplane at all
Robert: Controls to the left (….) what is that?
Bonin: I have the impression (we have) the speed
Dubois: [Returning to the cockpit] Er what are you (doing)?
Robert: What’s happening? I don’t know, I don’t know what’s happening
Bonin: We’re losing control of the aeroplane there
Robert: We lost all control of the aeroplane, we don’t understand anything,
we’ve tried everything
22. Unfolding Events /4
• The plane fell at 10-15,000 feet a
minute
• Bonin mistook stall buffet as a sign of
going too fast and reduced thrust and
applied the speedbrakes
• The crew rapidly de-structured – Bonin
and Robert made contradictory inputs
(repeated “dual input” warnings)
• Dubois and Robert realised what was
happening about 50 seconds before
impact, but it was too late to recover
• 4 minutes and 24 seconds elapsed
between disconnection and impact
23. Unfolding Events / 5
Robert: Wait, me, I have I have the controls, eh?
Synthetic voice: Dual input
Bonin: What is… how come we’re continuing to go right down now?
….
Bonin: Nine thousand feet
Dubois: Careful with the rudder bar there
Robert: Climb, climb, climb, climb
Bonin: But I’ve been at maxi nose-up for a while
Synthetic voice: Dual input
Dubois: No, no, no, don’t climb
Robert: So go down
Synthetic voice: Dual input
Bonin: Go ahead you have the controls we are still in TOGA eh
Synthetic voice: Dual input
24. 24
Points for Discussion
1. What went wrong here? To what extent were the pilots at fault?
2. Sense-making – why did the pilots struggle to make sense of this
situation? Why did their sense of situational awareness collapse, and with
what consequences?
3. In what ways was there a breakdown in team-working in this case?
4. What does AF 447 teach us about sense-making, team-working and
decision-making? How can this episode help us understand these
processes in more normal environments?
Concepts:
Mental models (Shared? Valid?)
Situational awareness?
Cue and frame?
Heedful inter-relating?
25. Wrap Up & Implications
• Extreme cases teach us a lot about the team processes necessary to
ensure team effectiveness in the face of demanding conditions
• It’s about:
– Being able to read your environment
– Develop a valid, shared representation of this and constantly update it
– Acting appropriately, conveying your actions to others and learning as you go
How?
• Conditioning - frequent and continuous small” challenges help develop
the capacity to be innovative and flexible
• Constant hands-on exposure keeps fundamental skills and awareness
fresh and ready
• We all have our equivalent of autopilot
26. Oliver, N., Calvard, T. and Potocnik, K. (2017) ‘Cognition, Technology and Organizational Limits:
Lessons from the Air France 447 Disaster’. Organization Science. Vol 28 No 4, pp 729-743.
http://pubsonline.informs.org/doi/abs/10.1287/orsc.2017.1138
Oliver, N., Calvard, T. and Potocnik, K. (2017) ‘The Tragic Crash of Flight AF447 Shows the
Unlikely but Catastrophic Consequences of Automation’. Harvard Business Review, 15
September 2017. https://hbr.org/2017/09/the-tragic-crash-of-flight-af447-shows-the-unlikely-but-
catastrophic-consequences-of-automation
28. Challenging Environments
Nature of Environment Nature of challenges for teams &
decisions
Complex Many variables to consider, distributed
information and cognition, boundary-
spanning issues
Dynamic Parameters constantly changing,
continuous updating need, high risk of ‘not
being on the same page’
Tightly-coupled Interconnectedness / interdependency –
changing one thing changes many others;
ripple effects; limited time to make
decisions and act
Contested Lack of agreement or disagreement on
goals; competing interests and priorities;
difficult to identify and agree on actions
29. “Things that have never happened
before happen all the time”
– Scott Sagan
