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Under Pressure, The Narrowing Cognitive Map: Lessons from the Tragedy of Singapore Airlines Flight 6

July 10, 2023 By Nagesh Belludi Leave a Comment

Picture this: You’re parking your car when, suddenly, you catch sight of the bus you desperately need to catch pulling into the station. Acting on instinct, you swiftly navigate your car into a vacant spot, deftly gather your bags, and launch yourself towards the bus stop, driven by an unwavering determination to evade a tedious fifteen-minute wait for the next one. In the whirlwind of your frantic sprint, you absentmindedly and hastily tuck your cherished cell phone into your back pocket, oblivious that it slips out during the adrenaline-fueled pursuit of catching the bus. It’s only after another five minutes that you become aware of your cell phone’s absence, and the weight of its loss gradually descends upon you.

Isn’t it fascinating how our minds tend to close off under time pressure? This fascinating cognitive phenomenon is known as the “narrowing of the cognitive map.” It’s as if our attention becomes laser-focused, but unfortunately, that can lead us to make unfortunate errors in judgment.

When we find ourselves in the clutches of tunnel vision, our thinking becomes constrained, and we unknowingly fall into the trap of limited perspective. Not only do we become so fixated on a specific course of action that we overlook crucial details in our environment, but we also become oblivious to the subtle signals whispering, “Something’s amiss.”

Inattentional blindness, indeed. It’s a common problem in high-stress situations, and it can have serious consequences, as in the following case study of the Singapore Airlines Flight 6 crash.

Speed Stress Causes Serious Breakdowns in the Reliability of Judgment

Flight 6’s tragic case accident occurred on October 31, 2000, at Taipei’s Chiang Kai-shek International Airport. Various factors contributed to the crash, including severe weather conditions, limited visibility, inadequate airport markings, and insufficient actions taken by both the pilots and air traffic controllers.

During a scheduled stop in Taipei on its journey from Singapore to Los Angeles, Flight 6’s flight crew became aware of an approaching storm. They realized that if they delayed the takeoff, they would have to wait for the storm to pass, resulting in a lengthy 12-hour delay. This interruption would have entailed making overnight arrangements for the passengers, disrupting the crew’s schedule, and potentially impacting future flight schedules involving the aircraft and company personnel. Consequently, the crew made the decision to expedite the departure and take off before the typhoon made landfall on the island.

The Rushed Pilots Missed Clues That They Were Taking Off on a Closed Runway

Under immense time pressure, the flight crew became singularly focused on expediting their takeoff in rainy and windy conditions before the weather conditions deteriorated further. Despite being instructed to taxi to Runway 05 Left, they deviated from the assigned route and instead positioned themselves on Runway 05 Right, which was closed for takeoff due to ongoing pavement repairs.

Complicating matters, a section of Runway 05 Right was still being used as a taxiway during the construction period. The signage at the entrance of the runway did not adequately indicate the presence of a stop sign and construction equipment along the converted taxiway.

Moreover, the local air traffic controller failed to provide progressive taxi or ground movement instructions, which would have been appropriate considering the low visibility during the taxi. However, due to the crew’s heightened sense of urgency, they neglected to request step-by-step instructions for their taxi route.

Misleading Airport Markings Contributed to Pilots’ Mistaken Belief of Correct Runway Selection

In the midst of low visibility and feeling rushed, the pilots neglected crucial resources that could have guided them to the correct runway, such as runway and taxiway charts, signage, markings, and cockpit instruments. This lapse in judgment resulted in a loss of situational awareness, leading them to initiate takeoff from a runway closed for construction.

The Harsh Reality of Rushing: Examining the Aftermath of Singapore Airlines Flight 6's Closed Runway Mishap Approximately 3,300 feet down the runway, around 11:17 PM that night, the Boeing 747 collided with concrete barriers and construction equipment, resulting in the aircraft breaking apart and bursting into flames.

Tragically, 83 out of the 179 people on board lost their lives.

The crew’s loss of awareness was further compounded by the airport’s negligence in terms of maintenance and safety precautions. By failing to place mandatory construction warnings at the entrance of Runway 05 Right, they disregarded the potential risk of aircraft mistakenly attempting to take off from a partially closed runway.

The air traffic controllers also neglected to verify the aircraft’s position before granting takeoff clearances, despite the aircraft having turned onto Runway 05 Right. The airport lacked the necessary Airport Surface Detection Equipment, which could have been crucial in detecting and mitigating risks, especially given the heavy precipitation that could have hampered radar presentation at the time. In their defense, the pilots had assumed that the air traffic controllers could visually observe the aircraft, and the fact that takeoff clearance was issued just as the aircraft turned onto the taxiway gave them the impression that everything was in order.

Anxiety Leads to Attentional Tunneling and Narrowed Field of Focus

The tragedy of Singapore Airlines Flight 6 serves as a poignant case study highlighting the dangers of tunnel vision and its ability to hinder our perspective and decision-making.

Often, seemingly minor errors, when combined with time constraints and cognitive biases, can intertwine and escalate, leading to catastrophic outcomes. Even in a highly advanced cockpit and a complex system with numerous safeguards, a chain of minor errors can transform it into a deadly trap.

The human brain is naturally inclined to seek confirmation and convince itself that it completely understands the situation at hand. When faced with contradictory information, we tend to ignore it and focus solely on our preconceived notions. Furthermore, anxiety further impairs our ability to perceive the entire situation, leaving us prone to impulsive actions rather than rational responses.

It is vital to be aware of the perils of tunnel vision. It can close our eyes to the broader context and limit our capacity to consider peripheral information. This narrowed perception can have severe consequences, emphasizing the importance of maintaining a broader perspective in decision-making.

Wondering what to read next?

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  2. “Fly the Aircraft First”
  3. How Stress Impairs Your Problem-Solving Capabilities: Case Study of TransAsia Flight 235
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  5. What Airline Disasters Teach About Cognitive Impairment and Decision-Making Under Stress

Filed Under: Business Stories, Effective Communication, Sharpening Your Skills Tagged With: Aviation, Biases, Conflict, Decision-Making, Mindfulness, Problem Solving, Risk, Stress, Worry

After Action Reviews: The Heartbeat of Every Learning Organization

June 15, 2023 By Nagesh Belludi Leave a Comment

The After Action Review (AAR) is a formal group reflection process used by the military and other organizations to analyze critical decisions or moves.

At its core, the AAR seeks to answer four questions: What was planned, what actually happened, why did it happen, and how can we do better next time?

The focus isn’t on grading success or failure but on identifying weaknesses that need improvement and strengths that should be sustained. The knowledge gained from the AAR can then be shared with others who’re planning, developing, implementing, and evaluating similar efforts.

Conducted in an open and honest climate, the AAR involves candid discussions of actual performance results compared to objectives. It requires input and perspectives from all stakeholders involved in the project or activity. The goal is to ensure everybody feels part of the solution, not the problem.

AARs are a powerful tool for continuous improvement that enables organizational learning through reinforcing personal and organizational accountability and continuous assessment of performance successes and failures. They’re an excellent way to identify best practices (what should be spread) and errors (what shouldn’t be repeated.)

The wisest and smartest people and businesses can reflect ex post facto. As the saying goes, “He that will not reflect is a ruined man.”

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Filed Under: MBA in a Nutshell, Mental Models, Sharpening Your Skills Tagged With: Creativity, Critical Thinking, Decision-Making, Meetings, Problem Solving, Risk, Teams, Thought Process

Availability Heuristic: Our Preference for the Familiar

May 27, 2023 By Nagesh Belludi Leave a Comment

The availability heuristic is a cognitive bias that can lead people to rely on readily available information or emotionally charged and inherently interesting examples when making decisions or judgments. Essentially, individuals tend to overestimate the probability of events that are easy to recall or that they’ve personally experienced, while underestimating the likelihood of less memorable or less frequent events.

In other words, the ease of retrieval of a misleading cue may make people rely on evidence not because it is dependable but because it is memorable or striking and thus psychologically available to them. They may do so even if the evidence is not logically acceptable or does not logically support their decision.

Doctors often depend on recalling their past dramatic cases and mistakenly apply them to the current situation. People may overestimate the crime rate in their community based on news coverage, even though crime rates may be relatively low. People may dismiss the reality of climate change if they’ve recently experienced a cold winter or heard of a cold snap in a particular region, even though global warming is a long-term trend. Individuals are more likely to purchase insurance after experiencing a natural disaster than before it occurs. In each of these scenarios, the vivid and emotional evidence feels more persuasive rather than it being the most accurate or reliable information.

The availability heuristic can also shape people’s perceptions of air travel safety and lead them to believe that flying is more dangerous than it really is. Airplane accidents are often sensationalized and highly publicized by the media, making them more memorable and more prominent in people’s minds. This can cause individuals to perceive the risk of flying much higher than it actually is, leading them to avoid air travel even though it is statistically one of the safest forms of transportation. In reality, many less vivid and less memorable (i.e., psychologically unavailable) things are much more dangerous than air travel, such as falling down stairs, drowning, choking, and accidental poisoning.

Avoid falling prey to the availability heuristic and making serious misjudgments about the risks associated with different situations. Acknowledge that personal experiences and recent events may not accurately reflect the overall reality of the situation.

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Filed Under: Mental Models, Sharpening Your Skills Tagged With: Aviation, Biases, Decision-Making, Mental Models, Problem Solving, Psychology, Risk, Thinking Tools

Don’t Outsource a Strategic Component of Your Business

May 11, 2023 By Nagesh Belludi Leave a Comment

The prescription eyeglasses retailer Warby Parker was launched by four drinking buddies at the Wharton School of the University of Pennsylvania. The founders intended to disrupt a high-profit margin industry by taking out the intermediary.

Selling prescription eyeglasses online (Warby Parker mostly sells via brick-and-mortar today) would also defy skeptics who preferred to see certain things—shoes, diamond rings, cars—in person and were disinclined to get them online. Warby Parker’s incumbent competitors, 39DollarGlasses.com and EyeBuyDirect.com, had sloppy websites. A crucial part of Warby Parker’s startup plan was to start a user-friendly website where shoppers could upload a photograph of themselves and try on glasses virtually.

At first, the founders outsourced the website, resulting in disastrous consequences. In an interview with Fortune magazine (1-Jun-2019,) co-founder & co-CEO David Gilboa reflected on the pitfalls of outsourcing critical business components:

None of us [the founders] was qualified to build the website, so we solicited proposals and got a handful of bids from agencies. We chose the cheapest option, but a few months in, we realized it was a mistake. Their execution wasn’t what they promised. So we ended up firing them.

Now we develop most of the technology we use in-house to ensure we maintain as much control over the customer experience as possible. We’ve developed our website and both of our apps internally.

Idea for Impact: Don’t outsource what you’re supposed to do best.

Outsourcing a core function may give you a short-term uplift, but you’ll fail to create the core expertise within your company. That’s necessary to build a sustainable competitive advantage. The vendor just isn’t as invested in your success.

Building know-how internally is more challenging, but it’ll pay off in the long run. Sure, you may need to tap an outsourced hire for specialized expertise that you lack. But concentrate on developing your core functions in-house. In fact, be as micro-managey as possible in the early days.

Leverage outside help for bookkeeping, legal, and everything else that doesn’t generate a competitive advantage.

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Don’t Hide Bad News in Times of Crisis

April 21, 2023 By Nagesh Belludi Leave a Comment

When a crisis hits, suppressing or obscuring bad news is often an impulsive reaction. Leaders can even exacerbate a crisis if bad news is marginalized, unaddressed, or ignored until it’s too late.

If you don’t frequently communicate with your key constituency, somebody else will. In the absence of honest information, your employees can develop their own perceptions of the problem and its implications.

Idea for Impact: Wise managers recognize the power of transparency and self-disclosure. Speak up early and candidly. If necessary, take a reputational hit today by disclosing problems; it’ll earn dividends. With a candid appraisal, people can turn their attention away from assigning blame to understanding the problem’s nature and helping you develop solutions.

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Filed Under: Effective Communication, Leadership, Managing People Tagged With: Crisis Management, Decision-Making, Leadership, Leadership Lessons, Problem Solving

Confirm Key Decisions in Writing

March 9, 2023 By Nagesh Belludi 1 Comment

All human dealings are subject to intended and (largely) unintended misunderstandings and misinterpretations. In fact, when an agreement is distasteful, it’s easy to misunderstand.

Confirm oral agreements, instructions, and understandings in writing at the first chance you get. Don’t rely on just memory.

After meetings, email all the participants recording what was discussed. That way, if there’s ever a debate about what was discussed in the meeting, there is a written record to review. Do this even for phone calls if what was discussed is important. A helpful template:

I am confirming the agreement we reached at our meeting this afternoon. We decided on the following provisions: A, B, and C. Let me know as soon as possible if this information is not accurate so we can finalize this part of our negotiations. Call me to discuss any necessary changes if this doesn’t reflect your understanding.

Idea for Impact: “If it wasn’t written down, it wasn’t said.” Documenting critical decisions—your interpretation of it at least—helps avoid future fracas. If you don’t receive a written protest or correction, your account of the meeting stands accepted.

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Filed Under: Effective Communication, Managing People, Mental Models Tagged With: Assertiveness, Conflict, Conversations, Critical Thinking, Leadership Lessons, Negotiation, Persuasion, Problem Solving

Three Rules That Will Decide If You Should Automate a Task

March 6, 2023 By Nagesh Belludi 1 Comment

To check if a process or a workstream is a good candidate for being automated, see if it meets all three of these criteria:

  1. The process must be a well-oiled machine. The requirements and outcomes are well established. Is the process stable enough to be automated?
  2. The process doesn’t need someone to engage with it each time. It doesn’t need manual intervention, oversight, excessive customization, or finesse. It runs in the backdrop; it’s boring and doesn’t require ‘higher-order’ thinking. Are there decision points within the process that require human intervention?
  3. The process is time-consuming. By automating it, will you save at least 4x what you’ll invest in automating it?

If the manual process is broken or doesn’t exist, then automating it before it’s a “well-oiled machine” may lead to mistakes and unnecessary rework. Establish success with the manual workflow before attempting to automate it.

Idea for Impact: Picking which processes to automate isn’t easy; yet, the closer you observe the workflow deeply, the sooner you can understand both the happy path to automation and the exceptions.

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Filed Under: Mental Models, Project Management, Sharpening Your Skills Tagged With: Artists, Creativity, Critical Thinking, Mental Models, Problem Solving, Productivity, Thinking Tools, Time Management

How to … Plan in a Time of Uncertainty

January 25, 2023 By Nagesh Belludi Leave a Comment

In periods of uncertainty and ambiguity, move away from annual plans and focus on the next three months. Reflect on the unpredictability of the future and stay on your toes by forging plans for unexpected scenarios so you won’t be caught flat-footed when that time comes.

Establish “trigger points” and “accelerate, maintain, or terminate criteria” in advance and keep an eye on key indicators to “wait and see” or “stay the course” should one of your planned-for scenarios materialize.

Idea for Impact: When the horizon is much shorter, operate with agility and allocate your resources in real time.

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  3. Under Pressure, The Narrowing Cognitive Map: Lessons from the Tragedy of Singapore Airlines Flight 6
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Filed Under: Leadership, MBA in a Nutshell, Mental Models Tagged With: Adversity, Conflict, Decision-Making, Persuasion, Problem Solving, Risk

“Fly the Aircraft First”

December 29, 2022 By Nagesh Belludi Leave a Comment

Today is the 50th anniversary of the Flight 401 disaster. I’ve previously cited how the crew of the ill-fated Eastern Airlines Lockheed L-1011 got so single-mindedly preoccupied with tackling a nose landing gear indicator light malfunction that they didn’t pay attention to the fact that their airliner was descending gradually into the Florida Everglades.

In summary, the pilots were too distracted to fly the aircraft. Human factors, specifically cognitive impairments, can precipitate distractions away from vital tasks.

The incident led to a breakthrough called Crew Resource Management (CRM.) This “human nature innovation” actively orients pilots to prioritize tasks in order of operational safety. The adage “Aviate, Navigate, and Communicate (A-N-C)” reinforces the ‘fly the aircraft first’behaviors until they’re internalized and become routine.

The top priority—always—is to aviate. That means fly the airplane by using the flight controls and flight instruments to direct the airplane’s attitude, airspeed, and altitude. Rounding out those top priorities are figuring out where you are and where you’re going (Navigate,) and, as appropriate, talking to ATC or someone outside the airplane (Communicate.) However, it doesn’t matter if we’re navigating and communicating perfectly if we lose control of the aircraft and crash. A-N-C seems simple to follow, but it’s easy to forget when you get busy or distracted in the cockpit.

Idea for Impact: “Fly the aircraft first.” Know when to set aside the seemingly important things to accomplish the more vital ones.

Wondering what to read next?

  1. Lessons from the World’s Worst Aviation Disaster // Book Summary of ‘The Collision on Tenerife’
  2. Under Pressure, The Narrowing Cognitive Map: Lessons from the Tragedy of Singapore Airlines Flight 6
  3. How Stress Impairs Your Problem-Solving Capabilities: Case Study of TransAsia Flight 235
  4. Jeju Air Flight 2216—The Alleged Failure to Think Clearly Under Fire
  5. What Airline Disasters Teach About Cognitive Impairment and Decision-Making Under Stress

Filed Under: Business Stories, Effective Communication, Mental Models, Sharpening Your Skills Tagged With: Anxiety, Aviation, Biases, Conflict, Decision-Making, Mindfulness, Problem Solving, Stress, Worry

Innovation’s Valley of Death: Case Study on the Bombardier CSeries

December 20, 2022 By Nagesh Belludi Leave a Comment

The discovery and development of an invention are usually easier relative to the creativity and resources required to make it a commercial success. Indeed, many entrepreneurs and intrapreneurs struggle to commercialize their idea meaningfully—establish the idea’s marketability to prospective backers, engage potential customers, and price and promote their product or service for a favorable return on investment. Consider this case study of the Bombardier CSeries jets—fated for misfortune for many years only to morph into the successful Airbus A220 series:

As a country, we habitually underinvest in R&D. And, when domestic champions like Bombardier do emerge, they often prove unable to turn their great ideas into commercially successful, globally dominant businesses.

In a knowledge economy, a country’s future prosperity is increasingly tied to its ability to generate and capitalize on innovative new ideas.

“The paradox is that while there is innovation going on in Canada, we do not observe the same level of commercialization and ownership of those innovations [as in other countries]. In many cases, inventions developed in Canada are then commercialized by foreign companies that keep much of that benefit.”

Idea for Impact: Don’t let your idea fizzle because they can’t take your sizzle to market. Focus not just on overcoming internal barriers but also on how to commercialize your innovation. Hire outside capabilities if necessary.

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Filed Under: Mental Models, The Great Innovators Tagged With: Aviation, Creativity, Entrepreneurs, Innovation, Persuasion, Problem Solving

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About: Nagesh Belludi [hire] is a St. Petersburg, Florida-based freethinker, investor, and leadership coach. He specializes in helping executives and companies ensure that the overall quality of their decision-making benefits isn’t compromised by a lack of a big-picture understanding.

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