Making Better Decisions

Copyright D Gurney 2006
Making
Better Decisions
This 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 this
Making 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.
The most frequent causal factor (74 percent) was poor

“professional judgment / airmanship” (i.e. decision making).
Another form of poor decision making, “press-on-itis,”
accounted for 42 percent of all occurrences.
Flight Safety Digest Nov 98 - Feb 99. Special FSF Report: “Killers in Aviation”
Speakers notes provide additional information, they can be selected by clicking the right mouse button in Slideshow
View,
View, select Screen, select Speakers notes.
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:

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 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
Making Better Decisions 3

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
Select, Assess, check SOPs

Controlled
Thinking
Risk Assessment
Consider Judgment
Situation
All
Awareness
Options Choice
Action
Experience
Knowledge
Check, reassess situation

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)
Stable Approach ? Most decision errors occur in routine operations, and involve
the failure to detect and understand the need for action
If you understand the situation the decision should be obvious

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
Controlled Thinking
Automatic Conscious
Routine Do not rush actions. Consider the
Skill situation before acting
Situation Trained For
Discipline, check the situation and
Awareness
Rule then choose the appropriate SOP
Unusual Novel
Rare events; consider all options,

Knowledge alternatives, and assess the risks
Your focus of attention controls what you think about.

Your mental discipline controls how you think
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
Controlled Thinking
Automatic Conscious
Routine Experience is special knowledge and
Skill behaviour relating to situations
Situation Trained For
Training improves knowledge and
Awareness
Rule experience, it is the basis of all SOPs
Unusual Novel
Situation assessment requires more

Knowledge information, time, comparison
Experience and Control surprise and stress.

Knowledge Consider all options.
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
Controlled Thinking Risk Assessment

Automatic Conscious
Consequences
Situation Consider
Severity
Awareness all
Likelihood
options
Probability
A safe outcome
Experience and There is always some uncertainty in an
Knowledge assessment; both for risk and benefit.
Decision making - Judgment and Choice

Judgement depends on ability and motivation; it requires:
An enquiring mindset, ask yourself “Why should I 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
Controlled Thinking Judgment and Choice

Automatic Conscious
Ability
Situation Consider
Awareness Motivation all
options
Expectation
Experience and Judgment always involves a choice,

Knowledge usually a time constraint, and stress.
Decision 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
Controlled Thinking Action and Evaluation

Automatic Conscious
Act
Situation Consider
Awareness Evaluate all
options
Feedback
Has the action solved the problem ?

Reassess the situation
Avoiding errors in Decision Making

Misdiagnosing the situation:
Failure to properly assess the situation may result in a wrong decision.
Focus your attention on risk assessment and time management.
Choosing the wrong option/course of action:
Poor discipline; violating rules or procedures is the wrong action.
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

Avoiding decision errors - Assessment

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 ”
What we think the situation is

Common Uncommon
Failure to recognise the situation Recognise an uncommon situation
Hazardous Error Success

Land when you should not Go Around when you should
Recognise a common situation Conservative error
Success Failure
Land when you should Go Around without need

ut c a e hT
no mmo C

Errors 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 failure’
Avoid
– Rushed decisions,
– Acting without thinking
– I Know better, or ‘out-thinking’ SOPs

Errors in decision making - Tactical decisions

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 consequences
Incorrect perception of risk
The more often you do something wrong (risky),

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.


- How we learn to make good 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:-

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 experience has been gained, how is this to be remembered?
Use your experience to direct your attention

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’)
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.

Experience requires willingness and concentration to
store applicable information in memory for future use.
Having experience does not guarantee you ‘expertise’.
Expertise depends on how you use what you have learnt.

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:-
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
The initial focus of attention should be on sizing up the situation
Rain
Light Moderate Heavy
Showers
Light Moderate
Storms
Thunder Normal Severe

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

and experience, by strengthening memories for future recall.

Making Better Decisions - Debriefing

We can learn after each flight and training session by considering:-
Plus points:
What was good. What went according to plan
Minus points:
What was not so good, and why. What didn’t you know
Interesting 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
Remember -
Don’t forget

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

increased with every risk assessment.
Ask questions to make sense of the risk.
State the options and considerations,
provide reasons with justification.
What were the exceptions and
assumptions; were they met ?

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

successful does not mean that
the next attempt will be.

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.
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
Memory
Attention trigger:
‘Approach
Pattern
Briefing’ Dry Headwind Braking r/w length
Tailwind technique a/c weight
Wet Think ahead
60% safety Approach

Runway
Contaminated Alternate margin speed
condition

Making Better Decisions - Training

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.
Natural decision making requires practice:-
Situation assessment
Improving knowledge
Controlled behavior
Risk assessment
Judgment
Decision making requires:
Willingness to learn
Continued practice
Self assessment
Train to fly
Critical thinking
Fly as you train
Briefing

Making Better Decisions - Summary
Decision making is:-

Correctly assessing the situation and
Choosing a safe course of action
Knowledge
Provides ‘patterns’ to assess situations and options for action
Enables greater visualization of consequences - ‘ what if ’
Attention
Provides control over what we look for and think about
Manages surprise, workload, and time pressures
Enables risk assessment and option selection
Experience
Enables faster pattern links with knowledge
Directs our attention to what is important
Provides more options for action
Discipline
Controls hazardous attitudes
Judgment
Seeks the safest option

– some are easier than others
Understand the situation

Choose a safe course of action
Consider the consequences and risk

… avoid the ‘can-do’ attitude, and a mindset of ‘ how do I do this ’
Ask ‘ should I be doing this ? ’

Making Better Decisions

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Copyright D Gurney 2006

Making Better Decisions

2. Improving decisions by avoiding errors

3. Making better decisions through experience

The most frequent causal factor (74 percent) was poor

The objectives of decision making in aviation are to:

Decision making must:

Making Better Decisions 3

Decision making - A thinking process

Select, Assess, check SOPs

Check, reassess situation

Making Better Decisions 4

Decision making – Situation Assessment

If you understand the situation the decision should be obvious

Making Better Decisions 5

Decision making - Thinking and Behaviour

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

The way you think controls your behaviour

Rare events; consider all options,

Your focus of attention controls what you think about.

Decision making - Knowledge and Experience

Situation assessment requires more

Experience and Control surprise and stress.

Decision making - Risk Assessment

Controlled Thinking Risk Assessment

Decision making - Judgment and Choice

Controlled Thinking Judgment and Choice

Experience and Judgment always involves a choice,

Decision making - Action and Evaluation

Controlled Thinking Action and Evaluation

Has the action solved the problem ?

Avoiding errors in Decision Making

1. Understand the situation

Making Better Decisions 11

Avoiding decision errors - Assessment

What we think the situation is

Failure to recognise the situation Recognise an uncommon situation

Hazardous Error Success

Recognise a common situation Conservative error

Land when you should Go Around without need

Making Better Decisions 12

Errors in decision making - The wrong action

mistaken belief that the altimeter or navigation position is correct.

‘No pilot intentionally chooses failure’

Making Better Decisions 13

Errors in decision making - Tactical decisions

The more often you do something wrong (risky),

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

Making Better Decisions 14

Making Better Decisions

Briefing and de briefing

Self reflection; by pay attention to:-

Making Better Decisions 15

Making Better Decisions - Experience

Years of flying or formal titles do not provide experience.

Making Better Decisions 16

Making Better Decisions - Maintaining Attention

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

Thunder Normal Severe

Making Better Decisions 17

Making Better Decisions - Briefing

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

Making Better Decisions 18