Situation Awareness: Key Resources

Flin, R. H., O’ Connor, P., and Crichton, M. (2008). Safety at the Sharp End: A Guide to Non-Technical Skills. Aldershot, UK: Ashgate Publishing.

Endsley, M. R. (1995a). Measurement of situation awareness in dynamic systems. Human Factors, 37(1), 65-84.

Endsley, M. R. (1995b). Toward a theory of situation awareness in dynamic systems. Human Factors, 37(1), 32-64.

Case Studies

Three Mile Island: In the early hours of 28 March 1979, a series of failures led to the loss of coolant to one of the reactors of the Three Mile Island nuclear energy plant in Harrisburg, Pennsylvania. The loss of coolant, and subsequent overheating of the nuclear core, led to a very nearly catastrophic accident. As part of the accident sequence, the control room operators failed to notice in a timely manner that critical valves had remained closed after maintenance had been performed in the days prior. Furthermore, the design of displays in the control room allowed the control room operators to assume other valves were closed, when in fact they were open. These failures of situation awareness led to the loss of coolant to the reactor. This case study involves issues relating to situation awareness that have their origins in system design, display locations and formats, and inaccurate mental models of the control room operators.

Elaine Bromiley: This case study involves a patient who tragically died while undergoing a routine operation. After commencing the induction of anaesthesia, the anaesthetist had difficulty maintaining oxygen levels and was unable to maintain an effective airway with several different sizes of laryngeal mask. The anaesthetist then attempted to intubate Mrs Bromiley, unsuccessfully. This situation escalated over the next few minutes to a situation known as ‘can’t intubate, can’t ventilate’, where the accepted protocol is to access the airway through a tracheotomy (incision into the windpipe). However, for the next 30 minutes, the anaesthetist and other colleagues continued with attempts to intubate. After over 30 minutes with very low blood oxygen levels, the procedure was abandoned, but Mrs Bromiley never regained consciousness.39 The case can be explored with respect to failures of DSA, with several good videos available online to support the case.

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