_ Making Better Decisions

8/8/2019 _ Making Better Decisions

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Copyright D Gurney 2006

Making

Better Decisions

Making

Better Decisions

This presentation provides an overview of how to improve situation awareness. It is intended to enhance the reader's understanding, but itThis presentation provides an overview of how to improve situation awareness. It is intended to enhance the reader's understanding, but it

shall not supersede the applicable regulations or airline's operational documentation; should there be any discrepancy appear between thisshall not supersede the applicable regulations or airline's operational documentation; should there be any discrepancy appear between this


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Making Better DecisionsMaking Better Decisions

Introduction

This visual guide provides information and guidance to improve decision making

skills. These skills require experience in recognizing and managing the

situation, and control of your thinking to enable a correct choice of action.

There are three sections:

1. The process of decision making

2. Improving decisions by avoiding errors

3. Making better decisions through experience

The material may be used for self study or as part of a formal training

presentation. The speaker notes provide additional information.

Speakers notes provide additional information, they can be selected by clicking the right mouse buttonSpeakers notes provide additional information, they can be selected by clicking the right mouse button in Slideshowin Slideshow

ViewView, select Screen, select Speakers notes., select Screen, select Speakers notes.

The most frequent causal factor (74 percent) was poorThe most frequent causal factor (74 percent) was poorprofessional judgment / airmanship (i.e.professional judgment / airmanship (i.e. decision makingdecision making).).

Another form of poor decision making, press-on-itis,Another form of poor decision making, press-on-itis,

accounted for 42 percent of all occurrences.accounted for 42 percent of all occurrences.

Flight Safety Digest Nov 98 - Feb 99. Special FSF Report: Killers in AviationFlight Safety Digest Nov 98 - Feb 99. Special FSF Report: Killers in Aviation


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Making Better DecisionsMaking Better Decisions 3

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Decision MakingDecision Making

Humans make decisions in most daily activities

Decision making involves situation assessment and then the location,

identification, and selecti

on of a suitable course of action:

The objectives of decision making in aviation are to:

Influence an outcome of events

Resist threats by avoiding them to ensure safe flight

Change or optimise a situation

Resolve the consequences of threats or errorsAchieve a specific objective

Recover from non-normal conditions

Decision making must:

Minimise risk, seek the safest outcome

Be proactive

- not just letting an outcome occur by default


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Decision making- A thinking processDecision making- A thinking process

Decision making is a process that depends on several factors:-

Understanding the situation, the problem, time available, workload, and risk

The control of our thinking, attention resource, and mental behaviorExperience and Knowledge to generate options

Risk Assessment and Judgment

Choosing a safe option

Taking action

Checking

ConsiderConsider

AllAll

OptionsOptions

SituationSituation

AwarenessAwareness

ControlledControlled

ThinkingThinking

ExperienceExperience

KnowledgeKnowledge

Risk Assessment

Judgment

Choice

Action

Check, reassess situationCheck, reassess situation

Select, Assess, check SOPs


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Decision making Situation AssessmentDecision making Situation Assessment

Situation assessment involves a continuous mental process of gathering

data, combining data into information, comparing and assessing its

relevance, and planning ahead. Looking for and gather data (sensing data)

Combining data into meaningful information (perception)

Understanding what the information means (comprehension)

Using your understanding to think ahead and reconsider the plan (projection)

Most decision errors occur in routine operations, and involveMost decision errors occur in routine operations, and involve

the failure to detect and understand the need for actionthe failure to detect and understand the need for action

Stable Approach ?

If you understand the situation the decision should be obvious


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Decision making- Thinking and BehaviourDecision making- Thinking and Behaviour

Different situations require different thinking behaviours:-

Routine operations involve well practiced behaviours - skills

Trained for situations involve rules and discipline to guide the use of SOPsUnusual situations require knowledge to define the problem and choose a solution

The skill in decision making is knowing how to behave in each situation

Experience will enable you to judge when and how to change behaviour

Controlled thinking directs your choice to the formulation of a safe option

The way you think controls your behaviour

Do not rush actions. Consider theDo not rush actions. Consider the

situation before actingsituation before acting

Discipline, check the situation andDiscipline, check the situation and

then choose the appropriate SOPthen choose the appropriate SOP

Rare events; consider all options,Rare events; consider all options,

alternatives, and assess the risksalternatives, and assess the risks

SituationSituation

AwarenessAwareness

Controlled ThinkingControlled ThinkingAutomatic ConsciousAutomatic Conscious

Your focus ofattention controls what you think about.

Your mental discipline controls how you think

RoutineRoutine

Trained ForTrained For

Unusual NovelUnusual Novel

SkillSkill

RuleRule

KnowledgeKnowledge


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Decision making- Knowledge and ExperienceDecision making- Knowledge and Experience

Experience enables easier, quicker, and better decisions:

Expert pilots are able to identify problem situations more accurately and recall more

options or alternatives actions than novices pilots.The generation of options requires understanding which comes from knowledge.

Mental models are the combination of knowledge and experience (recalled from

memory), and the sensed information from the real world.

What is the plan, what is intended recall items from memory

What has been trained for SOPs, normal and abnormal operations

What happened last time own experience and from observation of others

Experience andExperience and

KnowledgeKnowledge

Experience is special knowledge andExperience is special knowledge and

behaviour relating to situationsbehaviour relating to situations

Training improves knowledge andTraining improves knowledge and

experience, it is the basis of all SOPsexperience, it is the basis of all SOPs

Situation assessment requires moreSituation assessment requires more

information, time, comparisoninformation, time, comparison

SituationSituation

AwarenessAwareness

Controlled ThinkingControlled Thinking

Control surprise and stress.

Consider all options.

Automatic ConsciousAutomatic Conscious

RoutineRoutine

Trained ForTrained For

Unusual NovelUnusual Novel

SkillSkill

RuleRule

KnowledgeKnowledge



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Risk AssessmentRisk Assessment

Decision making- Risk AssessmentDecision making- Risk Assessment

Risk assessment requires consideration of the consequences (severity) of

any action or inaction, and the likelihood (probability) of failure or success.

Check that the planned action is relevant, will it achieve the objectiveSelect the safest outcome for the conditions

A perfect solution may not be available, but select the one that best meets

the planned objectives, i.e. it is sufficient to solve the problem and safe

Good risk assessment minimises biased judgment

Do not underestimate the significance of threats, or the

effect of errors; avoid interpreting cues too optimistically

Experience andExperience and

KnowledgeKnowledge

SituationSituation

AwarenessAwareness

Controlled ThinkingControlled Thinking

There is always some uncertainty in an

assessment; both for risk and benefit.

ConsequencesConsequences

SeveritySeverity

LikelihoodLikelihood

ProbabilityProbability

A safe outcomeA safe outcome

ConsiderConsider

allall

optionsoptions

Automatic ConsciousAutomatic Conscious


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Decision making- Action and EvaluationDecision making- Action and Evaluation

Evaluation is required after every assessment, thought, or action:

Is the situation really understood

Has all available knowledge been used

Are we paying attention to the important aspects

Have all options been considered and assessed for risk

Has the judgement and choice of action been made without bias

What was the plan, what was the expected result, has the objective been met

ActAct

EvaluateEvaluate

FeedbackFeedback

Has the action solved the problem ?Has the action solved the problem ?

Reassess the situationReassess the situation

ConsiderConsider

allall

optionsoptions

SituationSituation

AwarenessAwareness

Controlled ThinkingControlled ThinkingAutomatic ConsciousAutomatic Conscious

Action and EvaluationAction and Evaluation



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Avoiding errors in Decision MakingAvoiding errors in Decision Making

Misdiagnosing the situation:Misdiagnosing the situation:

Failure to properly assess the situation may result in a wrong decision.Failure to properly assess the situation may result in a wrong decision.

Focus your attention on risk assessment and time management.Focus your attention on risk assessment and time management.

Choosing the wrong option/course of action:Choosing the wrong option/course of action:

Poor discipline; violating rules or procedures is the wrong action.Poor discipline; violating rules or procedures is the wrong action.

Beware false memory, biased judgment, or giving in to peer pressure.Beware false memory, biased judgment, or giving in to peer pressure.

1. Understand the situation

2. Control surprise and stress

3. Assess time and immediate risk

4. Consider a wide range of options

5. Control thinking and action behaviour

6. Assess risks for each option, choose the safest

t



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Avoiding decision errors- AssessmentAvoiding decision errors- Assessment

Conservative error

Failure

Go Around without need

Recognise a common situation

SuccessSuccess

Land when you should

Recognise an uncommon situation

SuccessSuccess

Go Around when you should

Failure to recognise the situation

Hazardous ErrorHazardous Error

Land when you should not

What we think the situation isWhat we think the situation is

Common Uncommon

The

actu

Theactu

Com

mon

The situation cues may be misinterpreted, misdiagnosed, or ignored,

resulting in a wrong metal picture:

Ambiguous visual scene; illusions, poor weather, not scanning

The risk level may be misjudged:

Unaware of conditions; risks underestimated

Warning signs ignored; complacency, bad habit, lack of knowledge

The amount of available time may be misjudged.

Lack of time; time available underestimated, rushed decision, press-on-itis

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Errors in decision making- The wrong actionErrors in decision making- The wrong action

The action may not be retrieved from memory:

It was not known or not considered because of the circumstances of the situation.

e.g. incorrect EGPWS pull up due to lack of training, skill, or proficiency, or

mistaken belief that the altimeter or navigation position is correct.

Only one option for action may be considered when in fact several exist:

e.g. failing to refer to SOPs, or abnormal / emergency checklists.

Training and experience influence choices because people are prone to use plans and

procedures that have worked in the past, but poor practices of other pilots may influence

the choice.

No pilot intentionally chooses failureNo pilot intentionally chooses failure

AvoidAvoid

Rushed decisions,Rushed decisions,

Acting without thinkingActing without thinking

I Know better, or out-thinking SOPsI Know better, or out-thinking SOPs

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Press-on-itis :-Press-on-itis :-

A reluctance to change from the existing plan e.g. continue with a landing when a go

around would be a safer option.1. The situation is not recognized as requiring a change in the course of action:

Humans downsize situations until it appears justifiable; e.g. Continuing a steep approach in

a tailwind , or a high speed approach without correction.

2. The consequences of the action or inaction are not anticipated or evaluated:

Failure to consider outcomes of each option, what if

Misunderstanding of the consequencesIncorrect perception of risk

TheThe more often you do something wrong (risky),more often you do something wrong (risky),

but with a successful outcome, the happier you are with it and the less risky it seems.but with a successful outcome, the happier you are with it and the less risky it seems.

Be aware of conflicting objectives (safety vs. productivity, or completion of flight for

personal reasons); e.g. landing downwind or long to give a shorter taxi time.

Be aware of organizational goals which appear to outweigh safety goals:

Reluctance to use an option that involves a delay or cost;

e.g. over focus on on-time arrivals and departures.

Errors in decision making- Tactical decisionsErrors in decision making- Tactical decisions

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Making Better Decisions- How we learn to make good decisions

Making Better Decisions- How we learn to make good decisions

By surviving our bad decisions.By surviving our bad decisions.

Briefing and de briefing

Comparing the outcome with the plan

Adding knowledge provides experience and options

Self reflection; by pay attention to:-Self reflection; by pay attention to:-

What was good, not so good; what was interesting, and why?What was good, not so good; what was interesting, and why?

What was learnt; what is still unknown, how is this to be learnt?What was learnt; what is still unknown, how is this to be learnt?

What experience has been gained, how is this to be remembered?What experience has been gained, how is this to be remembered?

Use your experience to direct your attentionUse your experience to direct your attention

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Making Better Decisions- ExperienceMaking Better Decisions- Experience

Experience is gained from understanding situations and making decisions.

Continually practice making decisions in realistic scenarios

Form mental patterns of normal situations for future referenceConsider your limits and personal behaviour in routine operations

- how close were you to the edge of a safe boundary

Practice creating mental models of poorly defined situations, visualise

- learn to ask better questions to understand the current situation

Think ahead to consider the outcome of future situations for a range of actions

- consider the threats and risks of each action (what if)

Improve knowledge, never stop learning, have an enquiring mind, always seek an answer

- aircraft systems, SOPs, and operational and technical limits

Look for wider experiences both from others and safety documents

- have many examples as you can to fall back on

Years of flying or formal titles do not provide experience.Years of flying or formal titles do not provide experience.

Experience requires willingnessExperience requires willingnessandandconcentration toconcentration to

store applicable information in memory for future use.store applicable information in memory for future use.

Having experience does not guarantee you expertise.Having experience does not guarantee you expertise.

Expertise depends on how you use what you have learnt.Expertise depends on how you use what you have learnt.

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Making Better Decisions - Maintaining AttentionMaking Better Decisions - Maintaining Attention

With experience we can learn how to manage our attention;

what to look at, when, and why.

Our focus of attention:-

Improves situation awareness

Reduces uncertainty and ambiguity

Helps manage workload or time pressure

Provides a better understanding of the problem

Controls our behaviour in responding to the situation

Minimises the surprise and stress of unexpected events

Rain

Light Moderate Heavy

ShowersShowers

Light ModerateLight Moderate

StormsStorms

Thunder Normal SevereThunder Normal Severe

The initial focus of attention should be on sizing up the situationThe initial focus of attention should be on sizing up the situation

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Making Better Decisions - BriefingMaking Better Decisions - Briefing

We learn from briefings, they are the flight plan for the mind.

Planning and thinking ahead by visualising, enables:-

Preparation for events so that they can be done more efficientlyAnticipation of high workload situations; task and time reallocation

A reduction of unanticipated or surprising events which minimizes stress

A cross check of progress against the plan and an earlier recognition of situations

Mentally rehearsal by considering what if situations, adds to our knowledgeMentally rehearsal by considering what if situations, adds to our knowledge

and experience, by strengthening memories for future recall.and experience, by strengthening memories for future recall.

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Remember -Remember -

Dont forgetDont forget

Making Better Decisions - DebriefingMaking Better Decisions - Debriefing

We can learn after each flight and training session by considering:-

Plus points:Plus points:

What was good. What went according to planMinus points:Minus points:

What was not so good, and why. What didnt you know

Interesting points:Interesting points:

What was learnt, when, where, and why

What was the source of the information

Have you changed how you see thingsAny issues for a confidential report

Did you experience:-

Poor attitudes or biased opinions

High workload or time pressure

Unanswered questionsSurprise or stress

Memory failure

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Making Better Decisions - Assessing RiskMaking Better Decisions - Assessing Risk

We learn by considering the level of risk during all flight activities: -

Certainty: Stable conditions, where alternatives and outcomes are fully understood.

Risk: Some instability where alternatives have only probable outcomes.

Uncertainty: Highly unstable conditions, where alternative actions are poorly understood.

Choose the safest option because: it is appropriate for situation

it has superior outcomes to other alternatives

Are you a risk taker, or risk avoider ?

Knowledge and experience areKnowledge and experience are

increased with every risk assessment.increased with every risk assessment.

Ask questions to make sense of the risk.Ask questions to make sense of the risk.State the options and considerations,State the options and considerations,

provide reasons with justification.provide reasons with justification.

What were the exceptions andWhat were the exceptions and

assumptions; were they met ?assumptions; were they met ?

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Making Better Decisions - DisciplineMaking Better Decisions - Discipline

Without self-discipline we would learn the hard way:

Discipline enables us to:

Control our thinking behaviourAllocate the time available for action

Use the correct thought process and behaviour

The smallest change in conditions may overcome the plan:-

Do not tolerate SOP deviation, short-cuts, or thinking that you know better.

Resist peer pressure and bad habitsGive yourself an undo button

Because one marginal landing wasBecause one marginal landing was

successful does not mean thatsuccessful does not mean that

the next attempt will be.the next attempt will be.

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MakingBetter Decisions - RememberingMakingBetter Decisions - Remembering

We learn by storing experiences and knowledge in memory:

Pay attention; concentrate on what is said, seen, thought, and done

Visualise situations;see to understand and link this with thoughts andactions as patterns of behaviour for future reference.

Associate experiences with situations and the outcome of decisions;

the stronger the association, the easier the recall.

Items are more easily stored in memory by pattern coding, linking by association,

and chunking by grouping similar information together.

Memory can be biased to fit the apparent facts crosscheck and monitor the situation,

especially in a rapidly changing situation.

False memories may be recalled from previous bad habit operations or inappropriate

procedures from other aircraft types refer to current SOPs

RunwayRunway

conditioncondition

DryDry

WetWet

ContaminatedContaminated

r/w lengthr/w length

a/c weighta/c weight

60% safety60% safety

marginmargin

HeadwindHeadwind

TailwindTailwind

BrakingBraking

techniquetechnique

AlternateAlternate

ApproachApproach

speedspeed

MemoryMemory

PatternPattern

Think aheadThink ahead

Attention trigger:

Approach

Briefing

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Decision making is a skill that can be taught.Decision making is a skill that can be taught.

A loop process such as DECIDE helps novice pilots:-

Understand the principles and important issues

Provides a basis of practicing their ability

Decision making is a skill that can be improved.Decision making is a skill that can be improved.

Natural decision making requires practice:-

Situation assessment

Improving knowledge

Controlled behavior

Risk assessmentJudgment

Decision making requires:Decision making requires:

Willingness to learn

Continued practice

Self assessment

Critical thinkingBriefing

Making Better Decisions- TrainingMaking Better Decisions- Training

Train to flyTrain to fly

Fly as you trainFly as you train



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Making Better Decisions- SummaryMaking Better Decisions- Summary

Decision making is:-Decision making is:-

Correctly assessing the situation andCorrectly assessing the situation and

Choosing a safe course of actionChoosing a safe course of action

KnowledgeKnowledge

Provides patterns to assess situations and options for actionProvides patterns to assess situations and options for action

Enables greater visualization of consequences - what if Enables greater visualization of consequences - what if

AttentionAttention

Provides control over what we look for and think aboutProvides control over what we look for and think about

Manages surprise, workload, and time pressuresManages surprise, workload, and time pressures

Enables risk assessment and option selectionEnables risk assessment and option selection

ExperienceExperience

Enables faster pattern links with knowledgeEnables faster pattern links with knowledge

Directs our attention to what is importantDirects our attention to what is important

Provides more options for actionProvides more options for action

DisciplineDiscipline

Controls hazardous attitudesControls hazardous attitudes

JudgmentJudgment

Seeks the safest optionSeeks the safest option

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Making Better Decisions some are easier than others

Making Better Decisions some are easier than others

Understand the situationUnderstand the situation

Choose a safe course of actionChoose a safe course of action

Consider the consequences and riskConsider the consequences and risk

avoid the can-do attitude, and a mindset of how do I do this avoid the can-do attitude, and a mindset of how do I do this

AskAsk should I be doing this ? should I be doing this ?

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