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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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Copyright D Gurney 2006
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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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 ?