Klein - Streetlights and shadows: searching for the keys to adaptive decision making

Streetlights and Shadows

Searching for the Keys to Adaptive Decision Making

Gary Klein

A Bradford Book
The MIT Press
Cambridge, Massachusetts
London, England

2009 Massachusetts Institute of Technology

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Library of Congress Cataloging-in-Publication Data

Klein, Gary

Streetlights and shadows : searching for the keys to adaptive decision making / Gary Klein.

p. cm.

A Bradford Book.

Includes bibliographical references and index.

ISBN 978-0-262-01339-0 (hardcover : alk. paper)

1. Decision making. 2. Problem solving. I. Title.

BF448.K54 2009

153.83dc22

2009007501

10 9 8 7 6 5 4 3 2 1

to Helen, Devorah, and Rebecca

Contents

List of Examples

Acknowledgments

Notes

Bibliography

Index

List of Examples

A policeman saw a drunk searching for something under a streetlight. What have you lost, my friend? the policeman asked. My keys, said the drunk. The policeman then helped the drunk look and finally asked him: Where exactly did you drop them? Over there, responded the drunk, pointing toward a dark alley. The policeman then asked: Why are you looking here? The drunk immediately replied: Because the light is so much brighter here.

Streetlights and Shadows

Ten Surprises about How We Handle Ambiguous Situations

A commercial airliner isnt supposed to run out of fuel at 41,000 feet. There are too many safeguards, too many redundant systems, too many regulations and checklists. So when that happened to Captain Bob Pearson on July 23, 1983, flying a twin-engine Boeing 767 from Ottawa to Edmonton with 61 passengers, he didnt have any standard flight procedures to fall back on.

First the fuel pumps for the left engine quit. Pearson could work around that problem by turning off the pumps, figuring that gravity would feed the engine. The computer showed that he had plenty of fuel for the flight.

Then the left engine itself quit. Down to one engine, Pearson made the obvious decision to divert from Edmonton to Winnipeg, only 128 miles away. Next, the fuel pumps on the right engine went.

Shortly after that, the cockpit warning system emitted a warning sound that neither Pearson nor the first officer had ever heard before. It meant that both the engines had failed.

And then the cockpit went dark. When the engines stopped, Pearson lost all electrical power, and his advanced cockpit instruments went blank, leaving him only with a few battery-powered emergency instruments that were barely enough to land; he could read the instruments because it was still early evening.

Even if Pearson did manage to come in for a landing, he didnt have any way to slow the airplane down. The engines powered the hydraulic system that controlled the flaps used in taking off and in landing. Fortunately, the designers had provided a backup generator that used wind power from the forward momentum of the airplane. With effort, Pearson could use this generator to manipulate some of his controls to change the direction and pitch of the airplane, but he couldnt lower the flaps and slats, activate the speed brakes, or use normal braking to slow down when landing. He couldnt use reverse thrust to slow the airplane, because the engines werent providing any thrust. None of the procedures or flight checklists covered the situation Pearson was facing.