Making Better Decisions

Copyright D Gurney 2006
Making
Better Decisions
Making
Better Decisions
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Making Better Decisions Making Better Decisions
ntroduction
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. mproving 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.
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The most frequent causal factor (74 percent) was poor The most frequent causal factor (74 percent) was poor
"professional judgment / airmanship (i.e. "professional judgment / airmanship (i.e. decision making decision making). ).
Another form of poor decision making, "press Another form of poor decision making, "press- -on on- -itis, itis,
accounted for 42 percent of all occurrences. accounted for 42 percent of all occurrences.
Flight Safety Digest Nov 98 Flight Safety Digest Nov 98 - - Feb 99. Special FSF Report: "Killers in Aviation Feb 99. Special FSF Report: "Killers in Aviation
3
Decision Making Decision Making
Humans make decisions in most daily activities
Decision making involves situation assessment and then the location,
identification, and selection of a suitable course of action:
The objectives of decision making in aviation are to:
nfluence an outcome of events
Resist threats by avoiding them to ensure safe flight
Change or optimise a situation
Resolve the consequences of threats or errors
Achieve 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
4
Decision making - A thinking process Decision 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 behavior
Experience and Knowledge to generate options
Risk Assessment and Judgment
Choosing a safe option
Taking action
Checking
onsider onsider
AII AII
Options Options
Situation Situation
Awareness Awareness
ontroIIed ontroIIed
Thinking Thinking
Experience Experience
KnowIedge KnowIedge
Risk Assessment
Judgment
hoice
Action
heck, reassess situation heck, reassess situation
Select, Assess, check SOPs
5
Decision making - Situation Assessment Decision 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 involve Most decision errors occur in routine operations, and involve
the failure to detect and understand the need for action the failure to detect and understand the need for action
Stable Approach ?
f you understand the situation the decision should be obvious
6
Decision making - Thinking and Behaviour Decision 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 SOPs
Unusual 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 the Do not rush actions. Consider the
situation before acting situation before acting
Discipline, check the situation and Discipline, check the situation and
then choose the appropriate SOP then choose the appropriate SOP
Rare events; consider all options, Rare events; consider all options,
alternatives, and assess the risks alternatives, and assess the risks
Situation Situation
Awareness Awareness
ontroIIed Thinking ontroIIed Thinking
Automatic Conscious Automatic Conscious
Your focus of attention controls what you think about.
Your mental discipIine controls how you think
Routine Routine
Trained For Trained For
Unusual Novel Unusual Novel
SkiII SkiII
RuIe RuIe
KnowIedge KnowIedge
7
Decision making - Knowledge and Experience Decision 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 and Experience and
KnowIedge KnowIedge
Experience is special knowledge and Experience is special knowledge and
behaviour relating to situations behaviour relating to situations
Training improves knowledge and Training improves knowledge and
experience, it is the basis of all SOPs experience, it is the basis of all SOPs
Situation assessment requires more Situation assessment requires more
information, time, comparison information, time, comparison
Situation Situation
Awareness Awareness
Controlled Thinking Controlled Thinking
Control surprise and stress.
Consider all options.
Routine Routine
Trained For Trained For
Unusual Novel Unusual Novel
SkiII SkiII
RuIe RuIe
KnowIedge KnowIedge
8
Risk Assessment Risk Assessment
Decision making - Risk Assessment Decision 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 objective
Select 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
Knowledge Knowledge
Situation Situation
Awareness Awareness
There is always some uncertainty in an
assessment; both for risk and benefit.
onsequences onsequences
Severity Severity
LikeIihood LikeIihood
ProbabiIity ProbabiIity
A safe outcome A safe outcome
Consider Consider
all all
options options
9
Decision making - Judgment and Choice Decision making - Judgment and Choice
Judgement depends on ability and motivation; it requires:
An enquiring mindset, ask yourself "Why should continue?
Making a considered choice to control the perceived risk
Seeking all options from memory and comparing them
Stating all of the assumptions in the mental model
Recognizing that alternative actions are possible
Evaluating the consequences of any action
Controlling personal expectation and bias
Judgment and hoice Judgment and hoice
AbiIity AbiIity
Motivation Motivation
Expectation Expectation
Situation Situation
Awareness Awareness
Judgment always involves a choice,
usually a time constraint, and stress.
Consider Consider
all all
options options
Knowledge Knowledge
10
Decision making - Action and Evaluation Decision making - Action and Evaluation
Evaluation is required after every assessment, thought, or action:
s 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
Act Act
EvaIuate EvaIuate
Feedback Feedback
Has the action solved the problem ? Has the action solved the problem ?
Reassess the situation Reassess the situation
Consider Consider
all all
options options
Situation Situation
Awareness Awareness
Action and EvaIuation Action and EvaIuation
11
Avoiding errors in Decision Making Avoiding 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.
hoosing the wrong option/course of action: hoosing 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
12
Avoiding decision errors - Assessment Avoiding decision errors - Assessment
Conservative error
Failure
Go Around without need
Recognise a common situation
Success Success
Land when you should
Recognise an uncommon situation
Success Success
Go Around when you should
Failure to recognise the situation
Hazardous Error Hazardous Error
Land when you should not
What we think the situation is What we think the situation is
Common Uncommon
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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
13
Errors in decision making - The wrong action Errors in decision making - The wrong action
The action may not be retrieved from memory:
t 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 failure' 'No pilot intentionally chooses failure'
Avoid Avoid
Rushed decisions, Rushed decisions,
Acting without thinking Acting without thinking
Know better, or 'out Know better, or 'out- -thinking' SOPs thinking' SOPs
14
Press Press- -on on- -itis : 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 consequences
ncorrect perception of risk
%he %he 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 decisions Errors in decision making - Tactical decisions
15
Making Better Decisions
- How we learn to make good 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 attention Use your experience to direct your attention
16
Making Better Decisions - Experience Making 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 reference
Consider 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')
mprove 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 willingness Experience requires willingness and and concentration to concentration 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.
17
Making Better Decisions - Maintaining Attention Making 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:-
mproves 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
Showers Showers
Light Moderate Light Moderate
Storms Storms
Thunder NormaI Severe Thunder NormaI Severe
The initial focus of attention should be on sizing up the situation The initial focus of attention should be on sizing up the situation
18
Making Better Decisions - Briefing Making 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 efficiently
Anticipation 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 knowledge Mentally 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.
19
#emember #emember - -
Don't forget Don't forget
Making Better Decisions - Debriefing Making 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 plan
Minus points: Minus points:
What was not so good, and why. What didn't you know
nteresting points: nteresting points:
What was learnt, when, where, and why
What was the source of the information
Have you changed how you see things
Any issues for a confidential report
Did you experience:-
Poor attitudes or biased opinions
High workload or time pressure
Unanswered questions
Surprise or stress
Memory failure
20
Making Better Decisions - Assessing Risk Making 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 are Knowledge 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 and What were the exceptions and
assumptions; were they met ? assumptions; were they met ?
21
Making Better Decisions - Discipline Making Better Decisions - Discipline
Without self-discipline we would learn the 'hard way':
Discipline enables us to:
Control our thinking behaviour
Allocate 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 habits
Give yourself an 'undo' button
Because one 'marginal' landing was Because one 'marginal' landing was
successful does not mean that successful does not mean that
the next attempt will be. the next attempt will be.
22
Making Better Decisions - Remembering Making Better 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 and
actions as patterns of behaviour for future reference.
Associate experiences with situations and the outcome of decisions;
the stronger the association, the easier the recall.
tems 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
Runway Runway
condition condition
Dry Dry
Wet Wet
Contaminated Contaminated
r/w length r/w length
a/c weight a/c weight
60% safety 60% safety
margin margin
Headwind Headwind
Tailwind Tailwind
Braking Braking
technique technique
Alternate Alternate
Approach Approach
speed speed
Memory Memory
Pattern Pattern
Think ahead Think ahead
Attention trigger:
'Approach
Briefing'
23
Decision making is a skill that can be taught. Decision making is a skill that can be taught.
A loop process such as DECDE 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
mproving knowledge
Controlled behavior
Risk assessment
Judgment
Decision making requires: Decision making requires:
Willingness to learn
Continued practice
Self assessment
Critical thinking
Briefing
Making Better Decisions - Training Making Better Decisions - Training
%rain to fly %rain to fly
Fly as you train Fly as you train
Making Better Decisions - Summary Making Better Decisions - Summary
Decision making is: Decision making is:- -
Correctly assessing the situation and Correctly assessing the situation and
Choosing a safe course of action Choosing a safe course of action
Knowledge Knowledge
Provides 'patterns' to assess situations and options for action Provides 'patterns' to assess situations and options for action
Enables greater visualization of consequences Enables greater visualization of consequences - - ' what if ' ' what if '
Attention Attention
Provides control over what we look for and think about Provides control over what we look for and think about
Manages surprise, workload, and time pressures Manages surprise, workload, and time pressures
Enables risk assessment and option selection Enables risk assessment and option selection
Experience Experience
Enables faster pattern links with knowledge Enables faster pattern links with knowledge
Directs our attention to what is important Directs our attention to what is important
Provides more options for action Provides more options for action
Discipline Discipline
Controls hazardous attitudes Controls hazardous attitudes
Judgment Judgment
Seeks the safest option Seeks the safest option
25
- some are easier than others
- some are easier than others
Understand the situation Understand the situation
Choose a safe course of action Choose a safe course of action
Consider the consequences and risk Consider the consequences and risk
. avoid the 'can . avoid the 'can- -do' attitude, and a mindset of ' how do do this ' do' attitude, and a mindset of ' how do do this '
Ask Ask ' should be doing this ? ' ' should be doing this ? '

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Copyright D Gurney 2006

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