In this paper we provide a set of observations, recorded in the context of incident command operations at an airport mass casualty exercise, that emphasize the need for cognitive engineering in the design of socio-technical systems such as this one. Observations of inadequate communication resources, insufficient leadership, and malfunctioning equipment were made. These shortcomings appeared to hinder team decision making and team communication capabilities. Our observations also revealed potential areas for improvements in the operation of airport incident command systems.
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