New Arctic Air Crash Aftermath Role-play Simulation: Orchestrating a Fundamental Surprise

We describe an aviation scenario-based role-play simulation used to teach healthcare practitioners about barriers to learning from accidents. Participants searched for the causes of the crash in a scenario that encouraged a “garden path” explanation that the root cause was a risky decision to take off despite visible ice on the wings. During a debriefing session, the actual structure of how the system failed is revealed, including over 100 active and latent contributors to the failure with a multitude of potential lessons to improve safety. The dissonance between lessons learned during the role-play and the potential lessons creates a “fundamental surprise” situation that allows oversimplified assumptions of how complex systems fail to be challenged.