“Are you sure about that?”– Understanding and Improving Decision Making

Dr. Nicklas Dahlstrom

Human Factors Manager

Successful Operations

Challenging Environment

Akobo Airport, 3 June 2016

Yambio Airport, 4 June 2016

Bor Airport, 12 May 2016

Bor Airport, 14 June 2016

Making Decisions ina Challenging Environment

(WFP, 2015)

The main hazards identified in 2015

Decision?

Fundamental Attribution Error A tendency to explain behaviour based on internal

factors, (e.g. personality), and to underestimate external

factors (e.g. instructions, time, rewards/punishment)

Hindsight Bias Knowing the outcome of a decision affects judgement of

it:

• Oversimplifying chain of events

• Overestimating likelihood of outcome

• Misjudging the data available at the time

• Overrating of the influence of SOP deviations

• Matching outcome with actions that went before it

Understanding Decision Making

“The Moment of Choice”Too much focus on this,

not enough on the process

Case Study: A320 from GAU to DEL

Paris, 23-26 March 2015 21st Flight Safety Conference

• Guwahati to Delhi

• Lucknow as alternate

• Weather – Fog in

Delhi

• Diversion to Jaipur

Initial

destination

Actual alternateInitial alternate

14:30: Entered hold due to

traffic and delay (dense fog

in Delhi)

Vectored

and

cleared for

ILS RWY

28

14:54: Approach

was discontinued

because below

CAT I minima

15:02: OCC contacted and

decision taken to divert to

Jaipur due to fuel

OCC reported Jaipur vis at 2000

m

(Jaipur minimum RVR: 800 m)

Estimated FOB at that time:

3600 kg

Case Study: A320 from GAU to DEL

15:23 at 25 NM DME from

Jaipur:

Reported RVR: 500 m (below

min)

Estimated FOB: 2700 kg

Flight crew discussed other

options:

Return to Delhi: 119 NM / 849 kg /

28 min

Ahmadabad: 347 NM / 2170 kg / 62

min Flight crew decided to continue to

Jaipur

At approximately 15:05:

Jaipur tower reported RVR:

1000 m

Case Study: A320 from GAU to DEL

Paris, 23-26 March 2015

21st Flight Safety Conference

Just above MDH

(230ft)

Reported RVR: 50m

Established on ILS RWY 27

(CAT I)

Reported RVR: 200m

AP disconnected at

200ft

Captain (PF)

reported

RWY lights in

sight Landing

continued

Case Study: A320 from GAU to DEL

Paris, 23-26 March 2015 21st Flight Safety Conference

Case Study: A320 from GAU to DEL

Paris, 23-26 March 2015 21st Flight Safety Conference

Case Study: A320 from GAU to DEL

Decision Making Errors

Paris, 23-26 March 2015 21st Flight Safety Conference

• No recognition of

situation – ambiguous

cues

• Conflicting goals

• Risk is underestimated

• Consequences not

anticipated/evaluated (Orasanu & Martin,

1998)

Decision Making

Seconds Minutes HoursSplit-second

Fuel

Weather

Medical

TCAS

GPWS

Wind shear

Rational

decision

making

Conditioned

reaction ?

All other

decisions

Natural

decision

making

Conditioned Reaction

Typical conditions:

• Clear trigger(s)

• Time is a critical factor

• No competing/complex

information available

• The aim is for reaction

to be correct and fast

Rational Decision Making

Typical conditions:

• Clear and specific goals

• Minimal time constraints

• Complete and correct info

• The aim is an optimal decisionOk, but if

we choose

to that …

Natural Decision Making

Naturalistic Decision Making = How experienced professionals make decisions under time pressure, with

uncertain and changing information, conflicting goals and high risk

I recognise

this problem.

I have encountered this before and have

something to guide my decision.

(Klein, 1999)

Natural Decision Making

Typical conditions:

• Unclear goals (+ risk)

• Available time is minimal

• Incomplete/incorrect info

and changing situation

• The aim is a decision

that is “good enough”

(Klein, 1999)

Natural Decision Making

Steps involved:

• Situation recognition(Based on cues from the situation)

• Serial option evaluation(Until get to “good enough” option)

• Mental simulation(To test option and have a plan)

This looks like…

This should

work…

If we do it this

way it will fix

the problem…

(Klein, 1999)

Conditioned Reaction

Condition / Problem:

• Clear trigger(s) TriggerProblemLocation

• Time is a critical factor

• No competing/complex information available Priority of action/distractions (from aircraft systems, ATC, etc.)

Train:

• Identifying and “mapping”

of trigger (Look in right

place)

• Fast and directed

reaction

• Focus on triggered

actions, avoiding

distractions

critical

Rational Decision Making

Conditions / Problem:

• Clear/specific goals

Competing/contradicting

goals

• Lots of available timeBias for quick decisions,

pressures on decision making

• Complete/correct infoLots of info, influence from

others, more info available

Train:

• Clarification and analysis

of goals, setting priorities

• Making use of time,

ensuring time to decide

• Seeking and sifting info,

ensuring full analysis

Optimal decision

Natural Decision Making

Train:

• Swift “read” of situation,

finding/recognising cues

• Focused evaluation of

options, one at a time

• Active process on how

chosen option will play

out

“Good enough”

Steps / Problem:

• Situation recognition Lack of experience, does not

know or is not able to read

cues

• Serial option evaluationTakes any option, tries to do

a full analysis of all options

• Mental simulationAbandoned or limited due to

pressure/stress of situation

Expertise Reversal Effect

(Kalyuga, 2007)

“Instructional guidance, which may be essential for

novices, may have negative consequences for

experienced learners.”

Develop what is already there!

– provide structure where there is none, but be

careful in enforcing structure where the already is

good experience

From FO to Captain

(Fischer & Orasanu,

1995)

FOs: Time and

SOPs

Study - Priorities in scenarios:

Captains: Risk and Time

Better Decisions= Safer and more Efficient Operations

• Analyse the situation and not the

person(Hindsight Bias and Fundamental

Attribution Error)

• Moment of Choice Process of

Decision

(Search “upstream” for understanding of

outcome)

• Train for different types of

decisions

SummaryFocus on Decision Making

The Vision

Thank you!

nicklas.dahlstrom@emirates.com