Cognitive Bias in The Cockpit: A Deadly False Sense of Normality

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O’Connor, Sam
Issue Date
Master of Business Administration
Dublin Business School
The purpose of this study was to explore the role of cognitive bias in the flight deck of commercial aircraft through historical aviation accident and incident reports, to establish the most common types of biases and whether a set of pre-existing conditions in the flight deck environment influence their presence during critical events. The role of cognitive biases in aviation decision making is of growing interest and their impact is noted in this study as their role in some of aviation’s biggest disasters and near misses in the past 15 years is revealed. The research on cognitive bias applied to this setting is somewhat in its infancy, with little research on what elements in the flight deck influence bias. A mixed methods approach was adapted, and content analysis was applied to quantitively measure the qualitative data contained in 25 official commercial aviation accident and incident reports in which cognitive bias was mentioned in the report as having affected or influenced the crew. The Bowtie risk analysis framework, which is a model to establish causal relationships in high-risk scenarios, was adapted and provided structure to the data collection and analysis. Several characteristics pertaining to the flight crew, the operation and the environment were collected and analysed for each report, alongside the types of biases present and the outcome detailed in the report. This study revealed that cognitive bias disproportionally involved more accidents than incidents during conditions that tended to be more favourable than not. The flight crew were experienced and disproportionately not suffering from fatigue, with the captain occupying the pilot flying role more frequently. Certain biases were found to be more present at different phases of flight and there was disproportionally no aircraft malfunction during the events analysed. Cognitive bias also didn’t appear to discriminate between daylight or darkness, good or poor weather conditions. This research provides valuable insight into the impact of cognitive bias on flight safety and reveals some of the conditions under which cognitive bias thrives in the environment of commercial aircraft. This study sets the foundations for future research which should focus around developing supporting flight crew with debiasing education and techniques to further improve the safety of the industry.