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Procedures can result in worse performance


Dr. Kathleen Mosier of San Francisco State University discussed an experimental electronic checklist that NASA developed, in which completed items were sensed and “checked-off.” The idea is that this was to be a procedural aid, a back-up to the crew going through their checklist. A research study found that instead, the electronic checklist became the primary indicator of the event for the crew.

During a simulated bird-strike event, the electronic checklist instructed the pilots to shut down the wrong engine, to which five out of eight crews complied. This, despite information in the cockpit that was contrary to what the checklist was showing! Even more amazing, in a similar study involving a false engine fire, 67% of those who shutdown an incorrect engine “remembered” seeing confirmatory data on their instruments where none existed.

So are procedures to be abandoned? A subsequent study showed that part of the bias the electronic procedures created was due to how they were presented. The electronic checklist was given excessive saliency in its presentation – bigger, more centrally located, so the users tended to defer to it. The automation had “authority.” When given less saliency, the bias created by the checklist was reduced. So the issue is not procedures per se, but how the procedural information is presented.

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