After any-air disaster, technical failure is often the first target of any inves-tigation. But what if the causation lies not in a fatal weakness in the aircraft, but rather in a fatal weakness in the dynamics of the cockpit crew? One of the greatest challenges for individuals working in high-risk environments is making safety-critical decisions once a task has started. These individuals, whether in aviation, the fire service, the military, process engineering or healthcare, are truly at the sharp end. Whoever else has helped the individual to reach this point - through design of the task, maintenance of equipment, or preparation of the workplace -it is the person flying the plane or directing the operation who must make choices and take decisions in a changing, perhaps volatile, situation. These frontline operatives take minute-to-minute responsibility for ensuring a safe outcome.
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