Missed Opportunities:: The Great Bear Wilderness Disaster

Abstract

On a stormy September day, a Cessna departed Glacier National Park International Airport in Montana for a 30-minute flight into the Bob Marshall Wilderness. The four forestry scientists aboard never made it to their work site. Their pilot got lost and turned into a box canyon -- a narrow structure with an entrance and mountain walls but no exit. At the end of the canyon, the pilot tried to execute a last-minute emergency turn, but the plane crashed into solid granite and burst into flames. An eyewitness who saw the plane provided a map of its location to federal authorities but this information was not given to local agencies, so search and rescue efforts were concentrated in the wrong place. When the crash site was located the next day, the sheriff declared that the accident was not survivable. All five aboard were confirmed dead and the ground search was halted. The following day two survivors, one in bad condition, walked out of the wilderness of their own accord. The plane crash in the Montana wilderness is used as an exemplar to demonstrate how crises escalate in organizations. Three simple mistakes -- the breakdown of coordination, the rush to judgment and the neglect of employee selection standards, as well as latent conditions related to these mistakes -- contributed to an organizational disaster. Attribution errors, the Robinson Crusoe syndrome, the rush to judgment, lack of training and experience, overconfidence bias, availability heuristics and other management shortcomings contributed to an organizational accident.