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马卡鲁峰空难行动:认知与人为因素对决策的影响

Operation makalu air crash: influence of cognitive and human factors on decision-making.

作者信息

Dahal Samarika, Chaudhary Gopal Kumar, Agrawal Nitin Kumar

机构信息

Department of Dentistry, Institute of Medicine, Kathmandu, Nepal.

Department of Forensic Medicine, Maharajgunj Medical Campus, Maharajgunj, Kathmandu, Nepal.

出版信息

Forensic Sci Res. 2023 Feb 12;7(4):803-807. doi: 10.1080/20961790.2022.2095691. eCollection 2022.

Abstract

Two onboard crew members lost their lives in the fatal Makalu Air Cessna Grand Caravan 208B domestic cargo flight crash on May 16, 2018. The Disaster Victim Identification (DVI) procedure comprises external examination, photography, DNA collection, fingerprint collection, postmortem examination, antemortem information collection from the family members, and reconciliation. The major challenge of this operation was dealing with cognitive bias. The antemortem dental information of one of the deceased was revealed to the forensic experts just before the postmortem examination. This influenced the testing strategies. There was a tendency to neglect the complete dental examination presuming the identification was established. Later, during a thorough examination, the forensic odontologist realised that the initial decision was erroneous. Furthermore, there are few experience-based resources available to resolve cognitive bias issues. The authors begin by summarising complicated operations in which they have been involved, followed by a discussion of the key sources of cognitive bias along with the solution to resolve these issues in DVI preparedness planning.

摘要

在2018年5月16日致命的马卡鲁航空赛斯纳大篷车208B型国内货运航班坠毁事故中,两名机上机组人员丧生。灾难受害者身份鉴定(DVI)程序包括外部检查、拍照、DNA采集、指纹采集、尸体解剖、从家庭成员处收集生前信息以及核对。此次行动的主要挑战是应对认知偏差。在尸体解剖前,法医专家才得知其中一名死者的生前牙科信息。这影响了检测策略。由于假定身份已确定,存在忽视全面牙科检查的倾向。后来,在彻底检查过程中,法医牙科学专家意识到最初的判断是错误的。此外,几乎没有基于经验的资源可用于解决认知偏差问题。作者首先总结了他们所参与的复杂行动,随后讨论了认知偏差的关键来源以及在DVI准备计划中解决这些问题的方法。

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