How Technical Teams Can Scan & Focus to Improve Situational Awareness
Updated: Sep 21, 2021
~ "I don’t know why we didn't see the voltage drop,” said an Engineer in an electric power utility
~ "I can't understand how we didn't notice that warning sign!" said a Scientist in a research laboratory.
~ "How could we have missed seeing that the insulators weren’t loaded?!" said a construction contractor on a jobsite.
Situational Awareness -- the ability to notice mission-critical, non-obvious elements in a dynamic work environment -- is essential to smooth, safe, reliable operations.
It’s easy to find models that describe how Situational Awareness might work. But finding a clear, practical, non-obvious method you can use to actually improve Situational Awareness in practice… that’s much harder.
In this article, you’ll discover a unique method you can use to improve Situational Awareness in your team, and how I came to use it. If you want to jump right to the Scan & Focus model itself, just skip to Section 5.
1. Eastern Airlines Flight 401
On December 29th, 1972, Eastern Airlines flight 401 departed from New York’s JFK airport. It was bound for Miami with 176 passengers and crew.
Just after 11:30pm, as they approached Miami, the pilot lowered the landing gear. He expected to see three green indicator lights to confirm that the landing gear on both wings and in the front of the aircraft had successfully lowered and locked into place for a safe landing.
He saw only two lights.
The indicator light for the front landing gear stayed dark.
Was the front landing gear truly malfunctioning? Had the 3rd green bulb simply burned out? Or had something else happened?
After setting the autopilot, Captain Bob Loft, First Officer Bert Stockstill and Flight Engineer Don Repo all immediately focused on solving this urgent problem. They tried cycling the front landing gear manually. But the 3rd bulb still wouldn’t light up. They tried to visually inspect the front landing gear via a tiny porthole in a cramped space. But they couldn’t see it clearly.
The crew focused on solving this urgent problem for about 30 minutes, until just before midnight. Then, they realized something:
Stockstill: We did something to the altitude.
Stockstill: We're still at 2,000 feet, right?
Loft: Hey—what's happening here?
Less than 10 seconds later, they crashed into the Florida Everglades.
Loft, Stockstill and Repo perished along with 98 other passengers and crew.
The National Transportation Safety Board (NTSB) investigation revealed that there was nothing wrong with the front landing gear. As Captain Loft had initially suspected, the 3rd green indicator bulb had simply burned out.
Sometime after setting the autopilot, one of the three men had accidentally bumped the control stick of the aircraft. This disengaged the autopilot. The plane started descending. But the descent was so slow that none of the three men sensed it. Since it was near midnight and quite dark, they could not see the terrain through the windows. Most surprisingly, none of the three men responded to the loud alarms warning them they were dangerously close to the ground until it was too late. (source)
The NTSB concluded that the cause was,
“…the failure of the flight crew to monitor the flight instruments during the final four minutes of flight, and to detect an unexpected descent soon enough to prevent impact with the ground. Preoccupation with a malfunction of the nose landing gear position indicating system distracted the crew's attention from the instruments and allowed the descent to go unnoticed.” (source, pp.23-24)
In simple terms, they lost Situational Awareness.
2. What is Situational Awareness?
From 2004-2015, I served in the Safety & Training Department for a 3,600-person business unit in a Fortune 500 electric power utility.
Dozens of times, I heard leaders say things like,
“That incident wouldn’t have happened if the Operator had had better Situational Awareness.”
“OK, folks, as we get out there on storm duty, remember to always look for the unexpected. Dial your Situational Awareness up to maximum and keep it there.”
In April of 2010, I took over as the Human Performance Improvement (HPI) Lead for those 3,600 engineers, lineworkers, and other technical experts. On that day, it suddenly became my job to teach front-line experts and advise executive policy-makers on all aspects of HPI… including Situational Awareness.
The problem was no one seemed to know what Situational Awareness was, how it worked, or most importantly how to help real-world technical teams to improve it.
I asked wise Safety Specialists, experienced leaders, trusted colleagues, and even the outgoing HPI Expert whom I was replacing. Everyone gave me either an honest, “Well… I don’t really know,” or a vague, abstract answer like, “It’s about knowing what’s going on around you… It’s about paying attention and thinking ahead.”
I was stunned to realize that no one knew much more than I did.
I had to find out more about Situational Awareness.
Most other classic Human Performance defenses made good sense to me. For example:
~ A Checklist is a physical, tangible object. You can literally hold it in your hand. You can watch someone like a pilot, a surgeon, or an electric utility switch operator use it.
~ Three-Step Communication is a clear 3-step process. You can hear two front-line experts actually verbalize those three steps in-person or on a recorded call.
~ Confirming Terminology is less prescribed, yet still clear to hear when performed. Like this.
“Ok, folks, when you’re on the phone walking through a procedure, and you need to pause, do NOT say “OK...” That could mean you want to proceed. Instead let’s all say, “Stand by.” Please give me a thumbs up to confirm you’re good with using "Stand by" instead of "OK"…. Thanks.”
Situational Awareness is different.
~ You can’t hold it in your hand.
~ You can’t see or hear it being performed.
~ It’s not a step-by-step process you can follow or teach.
~ You can’t tell when you have it… or lose it.
You, right here, right now, as you’re reading this article… do you have Situational Awareness? How do you know you have it? Can you prove you have it?
If I were your boss, and I insisted that you lost Situational Awareness a few minutes ago, could you prove me wrong?
What specific techniques do you use to maximize your own Situational Awareness?
How can you help others improve their Situational Awareness?
If you’re lost for answers right now, you’re not alone.
As I researched Situational Awareness, I came to the conclusion that it's the most abstract, confusing and misunderstood of all the concepts associated with classic Human Performance & Reliability. (source, p.5).
And yet, a loss of Situational Awareness seems to be a factor in a majority of incidents.
“Approximately 85 percent of incident reports include a mention of loss of situational awareness.” (source).
So, finding a practical way to improve Situational Awareness would be a game-changer in helping technical experts work more reliably and safely.
3. Three Popular Models...and Why I Don't Use Them
Currently, the most well-known model of Situational Awareness comes from research by Dr. Mica Endsley. I have enormous respect for Dr. Endsley and her work. The depth of her research is stunningly impressive. As soon as I discovered her model, I tried to put it into practice.
Imagine standing in front of 30 electric utility line workers. These men and women work outdoors, often 40+ feet above ground, on live electric power lines.
They are men and women of action. They tend to be skeptical of any idea they can’t test out with their own hands. Now imagine their response when I told them that Situational Awareness is…
“The perception of environmental elements and events with respect to time or space, the comprehension of their meaning, and the projection of their future status.” (source).
Most of them grimaced like they had swallowed a bug. They looked at each other, rolled their eyes, crossed their arms, shook their heads… and tuned out.
They didn’t care about an academic definition.
They didn’t care what Situational Awareness was.
They didn’t care how Situational Awareness might work.
They DID care about learning a clear, practical way to stay more aware of mission-critical, non-obvious elements in their ever-changing work environments.
The problem with most great academic research is that it’s descriptive, but not prescriptive.
In other words, it may tell you how things work. But it doesn't tell you how to work things.
I realized I needed a different model.
The second popular model I found was the Cooper Color Model. (source). Created in 2006 by firearms expert Jeff Cooper, this model explained awareness in six color-coded levels describing states from unaware to overwhelmed.
Unfortunately, it seemed limited to military, police and other confrontation-based professions that nearly always involved shooting guns. In addition, Cooper’s six levels seemed somewhat arbitrary, (why not 4 levels or 7?). And they were nowhere close to being mutually exclusive. Cooper’s model, like Endsley’s didn’t seem to suggest many clear, practical, non-obvious ways to actually improve Situational Awareness in teams.
The third model I found was the OODA Loop (source). Developed by fighter pilot and military strategist John Boyd in the late 1970s, the OODA Loop recommends that we (1) Observe, (2) Orient, (3) Decide, and (4) Act.
Of the three models, this one struck me as the most practical. Why? Because it gave a step-by-step process that people could experiment with, adapt, verify... or disprove.
But it was developed for the lightning-fast world of military air-to-air combat –- dogfighting. And it seems to apply best in situations when we’re competing against an aggressive opponent. So like the Cooper model, its usefulness in more routine, day-to-day work where there is no opponent or "enemy" seems to be limited. And like the models from Endsley and Cooper, the OODA Loop seems to conflate pure Situational Awareness with the separate science of decision-making which is already complex enough on its own.
The drawbacks for all three of these popular models seemed to outweigh their benefits, at least for the kinds of industries and teams that I worked with.
I needed a more practical model.
4. The Basketball Insight
One of the best videos that people often use to illustrate the concept of Situational Awareness is this quick 90-second demo of what many call “The Basketball Study.” Here’s the link for personal use only.
***Spoiler ahead: If you haven’t seen the video, you’ll enjoy the rest of this article much more if you watch the video before you read any further.***
Researchers Christopher Chabris and Daniel Simons were astonished to find that about 50% of subjects in their research studies failed to notice unexpected changes like the one in the video. (source). And yes, I initially missed it, too.
Like Endsley, their research seemed primarily descriptive, not prescriptive. Their theory on attention was fascinating. But it didn’t seem to offer any particularly clear, non-obvious or practical methods that laypeople could easily use to improve their Situational Awareness, especially in teams.
I felt like I’d walked into another dead-end.
I watched hundreds of people miss the surprise in the basketball video -- usually about 33% - 50% of first-time watchers. But of course, many people did notice the surprise in the video. I wanted to know why. So, I talked with them.
That’s when something unexpected happened.
After a few dozen conversations, I realized that many people who noticed the gorilla in the video weren’t really focusing very intently on counting the number of basketball passes, as the instructions told them to do.
Instead, many of the people who noticed the gorilla either ignored the instructions or just decided to multitask and watch a bit of the video, then chat with a neighbor, then watch other people watching the video.
I realized that many of the people who noticed the gorilla were NOT mentally focusing at all. Their mental state could best be described as something more like “scanning.”
That’s when it hit me.
Some people who watched the video were primarily “Focused” on counting the passes. They were usually pretty accurate, but often missed the gorilla.
Others were primarily “Scanning” -- not looking for or at anything in particular. They usually weren’t as accurate in counting the number of passes, but they always noticed the gorilla.
People were either Scanning, or Focusing. But almost no one seemed to be able to successfully Scan AND Focus at the same time.
That insight changed everything.
Scanning & Focusing. That seemed a practical way to improve Situational Awareness. So, I tested it out. I purchased a copy of the basketball video to use in trainings. Then I invited large groups to watch the video… not as individuals, but as 2-person partnerships. I told one person in each pair to “Focus” -- to count the passes while the other person “Scanned.”
The percentage of partnerships with one Scanner and one Focuser who noticed the gorilla and accurately counted the passes… was nearly 100%.
5. The Scan & Focus Model
When you’re at work, you likely spend the majority (90%+?) of your time:
Examples of Scanning are:
A pool lifeguard keeping an eye on a dozen or more kids as they splash and play in the pool
An electric System Operator on a bluebird day keeping an eye on the big board showing the status of all 40+ substations and circuits in their area
A driver cruising down a busy highway at 70mph as dozens of other cars, trucks and motorcycles enter, use, and exit the highway
Examples of Focusing are:
A lifeguard confronting one kid who was running dangerously poolside
An electric System Operator who suddenly notices that Baker Street Substation suddenly tripped offline for no good reason
A driver cruising at 70mph who sees the brake lights on the car in front of her unexpectedly light up
The bad news is that your brain cannot Scan and Focus effectively at the same time.
You can switch states, of course. But each switch requires more time and effort. And to enter a state of deep focus, it may take about 20 minutes each time. (source).
So, to maximize Situational Awareness in a two-person team:
One person primarily Scans
The other person primarily Focuses
Both people communicate with each other often to share information, and also to stay aware of each other’s mental and physical state (e.g., stable, worried, frustrated, tired, angry, etc. or on their A-game.)
The main hazard of Scanning is fatigue. The main hazard of Focusing is tunnel vision. So take breaks, or switch roles to minimize those hazards as needed.
This process of Scanning, Focusing & communicating may be a practical way for teams of technical experts in high-hazard industries to maintain strong Situational Awareness.
Larger teams, or teams that work remotely from each other, or individuals who work alone, can adapt the basic principles above to suit their unique needs.
6. Real-World Examples & Evidence
A Paramedic and his driver respond to a family home. There has been a domestic dispute… and an unknown injury.
Scan - The driver Scans the area for potential threats, hazards, or other people.
Focus - The Paramedic Focuses on the patient to rapidly assess & treat their injuries.
Communicate - The Paramedic communicates key info about the patient that the driver can’t see, but needs to know, like what level Trauma center they’ll need to drive to, and how quickly. The Driver warns the Paramedic long before anyone gets close enough to disturb with them. She also monitors & communicates elapsed time.
A team of electric utility lineworkers arrive at a damaged tower. They need to assess and repair it. The line is energized at 7,200 Volts.
Scan – The Foreman actively Scans the work zone for hazards like unseen damage, or unexpected changes that the others can’t see.
Focus – The two Lineworkers in the bucket Focus on assessing and repairing the damage while staying safely away from the energized lines.
Communicate – The two Lineworkers communicate before each irreversible step so the Scanner can confirm their reasoning and ensure they don’t miss anything. The Scanner communicates essential updates like: any changes in circuit status, or an unexpected person approaching the truck.
A driver and a spotter are backing up a vehicle.
Scan – The spotter primarily Scans all the areas that the driver can’t see plus the area that he’s walking backwards into.
Focus – The driver Focuses primarily on the spotter. She depends on him to see what she can’t.
Communicate – The spotter constantly communicates via clear, well-known hand signals. The driver acknowledges each signal with an action or a nod.
A team of electric utility lineworkers needs to repair a cable in an underground confined space.
Scan – OSHA requires an “Attendant” who, “monitors the entrant, guards the space against unauthorized entry, warns the entrants of any unusual conditions and summons rescue personnel if needed." (Scans). (source).
Focus – The Lineworker in the confined space focuses primarily on assessing and repairing the damaged cable.
Communicate – The Attendant and Lineworker stay in nearly constant contact to quickly detect and act on changes to relevant things like: the atmosphere within the confined space, or the psychological state of the Lineworker.
Is there evolutionary evidence for Scanning & Focusing?
Consider the Meerkat. After you get over how cute they are, recall the most well-known trait of Meerkats. Whenever the group is heads-down caring for their young, burrowing, or foraging for food (Focusing), at least one Meerkat literally stands watch for predators (Scanning). Thousands of years of evolution seem to show that this strategy is successful and adaptive, at least for Meerkats, and I suspect for many other species, including humans, too.
“The meerkat who is on guard duty will stand on its hind legs. By being in this position, they will be better positioned to scan the surroundings for predators…The meerkats know that having one or more meerkats standing guard means that they can concentrate on foraging for food.” (source).
Also, consider the Sentinel Hypothesis. Recent research suggests that occasional insomnia may be evolutionarily adaptive. Why? Dr. David Samson of the University of Toronto suggests that individuals in human tribes who wind up staying awake and alert in the middle of the night may have evolved to act as Sentinels (Scanning) to help protect the rest of the tribe while they are sleeping (Focused, albeit unconsciously).(source).
Finally, consider the "Divided Brain." Many assume that the left hemisphere of our brain is reserved for linear, analytical reasoning, and the right hemisphere evolved to be more creative and holistic. But in his book, "The Master and His Emissary: The Divided Brain and the Making of the Western World," psychiatrist Ian McGilchrist offers a more complex and interesting explanation.
"The right hemisphere gives sustained, broad, open, vigilant alertness, whereas the left hemisphere gives narrow, sharply focused attention to detail..."
Remember Eastern Airlines Flight 401?
The NTSB concluded that the cause was,
“…the failure of the flight crew to monitor the flight instruments during the final four minutes of flight, and to detect an unexpected descent soon enough to prevent impact with the ground…” (source, pp.23-24)
A more practical explanation might be to say that when the 3rd light failed to illuminate, all three flight officers wound up Focusing on it. None of the three men Scanned. So at that moment, they lost their Situational Awareness of anything not directly related to the light, including the altitude of the aircraft.
By the time that Captain Stockstill started Scanning again, and realized, “We did something to the altitude,” it was too late. Ten seconds later they crashed.
If they had agreed that one person would stay in Scanning mode, while the other two worked on the light, they may well have been able to maintain Situational Awareness and land safely.
7. Practical Steps You Can Take
There’s only one way to find out if the Scan & Focus model will work for you in practice.
Try it out. Just do it safely. Here’s how.
Share this article with 1-2 of your most trusted colleagues. After they read it, then discuss it together. Decide if it’s something worth pursuing further.
Experiment with just discussing the concepts “Scan” and “Focus” in larger conversations that relate to Situational Awareness. Don’t try to change any other behaviors right now. Just decide if using those concepts is more useful to you than whatever other concepts you were previously using. If talking in terms of Scanning & Focusing helps you and your team think more clearly about Situational Awareness, that’s a good sign that you’ve found a practical model.
Ask your most experienced colleagues their opinion of the Scan & Focus model. Be open to their concerns. But also listen for responses like,
“Well, it’s funny, but now that you’ve started talking about Scanning & Focusing, I’m realizing that’s what I’ve been doing on many of my toughest high-hazard jobs for years. And yes, it’s really helped… I just didn’t know that it had a name. Now I do.”
I’ve literally heard that before from a 30-year veteran Power Line Worker. When I did, I knew that Scan & Focus wasn’t something new to everyone. It was just a new name for a proven practice that many experts have used for decades.
Speak with your most experienced front-line experts and influential leaders. Invite them to share their Success Stories of using the Scan & Focus model. Capture those stories in writing and if possible, on video. Collect that evidence as it grows. Share it with your strong Scan & Focus Advocates. When appropriate, share that evidence in small doses with your toughest skeptics, especially senior leaders.
Over time, if your front line experts and respected leaders use the terms Scan & Focus more and more, they will likely find themselves actually Scanning & Focusing more in practice without you or anyone else having to formally require or direct them to do it. If Scan & Focus works effectively in practice and is supported by a strong majority of your most respected people, then consider making it an official policy and practice.
Consider getting high-quality training and coaching on this skill.
This kind of bottom-up “Practice to Policy” approach may be far more effective than traditional top-down attempts to change culture.
You may think that there are some flaws with this approach to Situational Awareness.
You may think that there are several relevant authors, research studies or models which aren’t mentioned in this article, but should be.
You may even think that there are fundamental problems with the very concept of Situational Awareness itself.
In all three cases, you may well be right.
“All models are wrong, but some of them are useful.” (source).
My goal in this article was not to create an exhaustively detailed model for academics to argue about, nor one that’s 100% technically accurate, nor one that integrates all previous research.
Instead, my goal was to give front-line technical experts and leaders in high-hazard industries a clear, non-obvious, and practical way to improve Situational Awareness today, and for years to come.
I hope you’ll let me know if it worked.
Jake Mazulewicz, Ph.D. helps technical experts in high-hazard industries improve reliability, safety and engagement.