Lessons from Everest: The Interaction of Cognitive Bias, Psychological Safety, and System Complexity

Roberto, Michael A.

doi:10.2307/41166157

Cited by 104 publications

(70 citation statements)

References 11 publications

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“…This outbreak of highimpact weather resulted in the largest number of fatalities (8) to occur near the summit of Everest during a single event. In the ensuing years, a passionate and wide-ranging debate has been ongoing in an attempt to understand the factors that contributed to this tragedy (Boukreev and DeWalt 1999;Breashears 1999;Dickinson 1999;Krakauer 1999;Roberto 2002;Mangione 2003;Kayes 2004). Curiously absent has been a quantitative discussion of the meteorological conditions that gave rise to this storm and the storm's impact on the climbers' physiology.…”

Section: Doi: 101175/bams-87-4-465mentioning

confidence: 99%

Weather And Death On Mount Everest: An Analysis Of The Into Thin Air Storm

Moore¹,

Semple²

2006

Bull. Amer. Meteor. Soc.

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Section: Doi: 101175/bams-87-4-465mentioning

confidence: 99%

Weather And Death On Mount Everest: An Analysis Of The Into Thin Air Storm

Moore¹,

Semple²

2006

Bull. Amer. Meteor. Soc.

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“…Complex systems (e.g., air traffic control, nuclear power plants and Everest expeditions) are characterised by different elements that interact in ways that cannot be predicted beforehand, and where faults in one part cannot easily be isolated from the rest of the system (Roberto, 2002). A minor slip up in a complex system can therefore result in a domino effect where one faulty aspect triggers others.…”

Section: Complex Systems and Errorsmentioning

confidence: 99%

“…Roberto (2002) argues in his analysis of the Everest tragedy that besides cognitive biases and systems complexity (see above), the group climate was not optimal in either of the two expeditions. Self-reliance was discouraged, as was questioning the guides' decisions.…”

Section: The Summit Attempt and Why It Went Wrongmentioning

confidence: 99%

The tragic 1996 Everest expedition: a tale of error culture

Dyck¹

2009

NEJP

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Error occurrence cannot be fully eliminated. A strict differentiation between errors and their consequences is used to (a) discuss error prevention and error management, and (b) to show how organisations can promote an error mastery culture that combines the best of both. This article uses two 1996 Everest expeditions as an illustration of what can go wrong in complex high-risk systems. The point of this article, however, is not restricted to high-risk industries. A mastery error culture aims at control of negative error consequences − most relevant in high-risk industries − but also fosters positive error consequences needed for adaptation and innovation. The article discusses both general and recent empirical literature on safety, quality and error handling. (Netherlands Journal of Psychology, 65,(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)

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“…But for many, budget constraints loom large when it comes to maintaining appropriate fieldsafety practices 2 . And I understand these concerns.…”

Section: Safety Measuresmentioning

confidence: 99%