Clues to Loss of SA

These “clues” can warn of an error chain in progress – a series of events that may lead to an accident. Most accidents involving human error include at least four of these clues.

Ambiguity

Information from two or more sources that doesn’t agree.

Fixation

Focusing on any one thing to the exclusion of everything else.

Confusion

uncertainty or bafflement about a situation (often accompanied by anxiety or psychological discomfort).

Failure to fly the aircraft

Everyone is focused on non-flying activities.

Failure to look outside… everyone heads down.

Failure to meet expected checkpoint on flight plan or profile ETA, fuel burn, etc.

Failure to adhere to SOPs.

Failure to comply with limitations, minimums, regulatory requirements, etc.

Failure to resolve discrepancies – contradictory data or personal conflicts.

Failure to communicate fully and effectively – vague or incomplete statements.

Clues to Loss of SA (adapted from Bovier, 1997)