15.1 15.3 15.4 15.6 CHAPTER FIFTEEN - DECISION-MAKING AND RISK Contents INTRODUCTION THE MECHANICS OF DECISION-MAKING.......... ERRORS AND SOURCES AND LIMITS IN THE DECISION-MAKING PROCESS... PERSONALITY TRAITS AND EFFECTIVE CREW DECISION-MAKING... JUDGEMENT CONCEPT........ 215-7 COMMITMENT....... AS -7 CHAPTER 15 - REVISION QUESTIONS 15-8HUMAN PERFORMANCE DECISION-MAKING AND RISK 15.1 INTRODUCTION “Making a decision is committing to a course of action”. ‘The most important human factor of any flight is the decision-making process of the crew, Sound decisions will lead to a safe and successful outcome to the task whereas bad decisions may lead to disaster, Decision-making brings together many factors which haye already been studied individually during this course. Thus this most important topic deserves special consideration The difference between “deciding” and “decision-making” is, whereas “deciding” may be arbitrary or based on an emotion, “decision-making” is the step-by-step scientific process which is followed in order to reach a balanced and factual decision sometimes known as the Judgement Concept, “Deciding” will not be discussed in this Chapter. A decision must be made each time there are several possible ways of achieving a given end. The choice will depend on a) The aim to be achieved. b) ‘The personal preference of the decision-maker The aim of decision-making is normally unambiguous however, the personal preference of options to achieve that aim will be influenced by a host of variables, such as the personality and biases of the decision-maker, the stakes involved, perception, stress, emotion, training, past experience, motivation, commercial factors - to name but a few. However, it is possible to identify certain common factors that influence decision-making regardless of the circumstances. Fortunately the human being has a number of positive capabilities in the decision-making mechanism. a) The ability is capable of making decisions very quickly if involved in a “skill” which is well-learned and highly automated. b) The capability to be creative. ©) The capacity to be innovative. 4) The aptitude to cope with novel situations. ‘The human will (currently) consistently out-perform a machine in this area, We must remember that the commander of the aircraft is ultimately responsible for any decision made in the cockpit. 15-1 ‘© Oxford Aviation Services LimitedHUMAN PERFORMANCE DECISION-MAKING AND RISK 15.2 SO) DI THE MECHANI ISION-MAKING It is possible to expand on the British Airways D.O.D.A.R. concept (which h sady been discussed in the CRM Chapter of these notes) to include a number of important considerations, Diagnose Identify the most important/urgent problem, and Specify the aim or objective. Define objective Assess the time available, Collect information |) Collect information from every available source Obtain inputs from other members of the crew Risk assessment Assess ri Develop options Think through every option to its logical conclusion. Evaluate options Weigh and compare options. Decide Select the best option and decide. ‘ign tasks Assign tasks to the whole crew. Implement decision Supervise and monitor the execution of the decision. Consequences Monitor and evaluate consequences. Review and Feedback Review whether the situation remains the same and that the decision is still valid Return to step 1 Diagnosis and definition of the obje ‘Time assessment. ‘The value of the decision largely depends on how deeply the situation is understood. An accurate assessment often requires perception of a large number of cues - radar pictures, weather forecasts, visual topographical features, fuel consumption, engine status, aizport capabilities, and so forth, These cues, in turn, must be interpreted against a knowledge base in the long-term memory to accurately construct a mental model and diagnosis of the real situation. ive. Faulty diagnosis, and thereby setting out to solve the wrong problem, may be avoided by ensuring that confirmation of the diagnosis is obtained from other members of the crew at this ear . Should the pilot be by himseli*herself, this initial diagnosis of the problem must be deliberately and calmly double-checked. Definition of the objective must be crystal clear. Once the crew are certain that the diagnosis is correct, the objective normally is self-evident. 15-2 © Oxford Aviation Services LimitedHUMAN PERFORMANCE DECISION-MAKING AND RISK ision is “good” if it can be implemented within the time available. Contrary to popular it is unusual in flight that time dictates a very quick decision, Certainly, a rapid solution to an emergency on take-off or landing, or if the aircraft is flying close to the ground, is essential. However, on most other occasions, a crew can make time in the air. There options open to enable this to be done. Some of these could be e many a) An approach can be converted into an overshoot. b) The aircraft can be put into a hold while the problem is assessed and solved. c) Take-off may be delayed. d) Speed can always be reduced. e) Diversion is nearly always a option In spite of the possibility of an ersor of commission, the only effective solution when pilots expect to be short of time, is to prepare the decision in advance. Remember : Thorough flight preparation phis briefings before each high risk phase of flight provide the best guarantee against making decisions when under the pressure of time. Commercial considerations, such as fuel costs may encourage a pilot to self-impose a time restriction, Although it is easy enough from the classroom (@ view these as of small importance viz a viz safety, commercial considerations can put considerable pressure on aircrew and thereby colour their decisions. Collect Information. Every source of information must be utilised. Other members of the crew must always be included as one of the most important of these sources. The Commander's perception of the situation may well differ from that of the carl nv. If this is the case, and the crew is included as possible, into the decision-making process, the consequent discussion and analysis is almost certain to pre-empt a faulty diagnosis, Assess Risk. Due to the dynamics of the situation (particularly the speed of the aircraft), an action emanating from a decision is frequently irreversible - thus risk is involved In assessing risk, both the amount and the probability of that risk must be considered. Unfortunately experiments have found that humans are not skilled at assessing the probability of different outcomes and their resulting risks. A person will tend to overestimate the frequeney of a very rare, but beneficial/positive, occurrence. This bias explains why gambling and lotteries are pursued - because the low probability payoffs are perceived as occurring more frequently than they, in fact, do. 15-3 © Oxtord Aviation Services LimitedHUMAN PERFORMANCE DECISION-MAKING AND RISK On the other hand, peoples’ estimates of the frequency of unpleasant/negative events differ Highly available or well-published events are over-estimated (fatal aircraft accidents) whereas less salient events are greatly under-estimated (Airprox incidents, non-fatal accidents or the risk of contracting lung cancer through smoking). Categories of Risk. The pilot can be exposed to 2 types of risk : a) External or Objective Risk. External risk is the risk of an accident in the current situation, if no changes are made to the flight path or the operation of systems. b) Internal or Subjective Risk. Internal risk is the risk which reflects the inability of the crew to implement a solution due to lack of know-how or insufficient time to apply their know- how. It should be noted that the internal risk increases linearly as the deadline for making and implementing the decision approaches. A Risk Factor can be defined as anything that is likely to increase the likelihood of an accident occurring, Develop Options. Assuming that the assessed situation is identified as a problem that requires some action, the pilot must then generate plausible alternative courses of action such as Should the approach be continued ? Is it better to go into a hold to give more time to gain further information ? Should the aireraft return to base ? }ould the aircraft divert ? Evaluate Options. Each proposed course of action may have a different anticipated set of possible outcomes, All of these outcomes will have potential values associated with them (or costs, which may be termed as negative values). An evaluation of each outcome, together with its entailed risk assessment, is then made. Decide. The Commander's choice of options, or decision, should be that which produces the most value and the least cost. The option chosen should also lead to the most favourable expected outcome and which has the least risk. Sometimes it is not possible to have both and a compromise must, on occasions, be made. A decision could be, of course, to delay an action until current information is confirmed or until additional data is obtained Having make his/her decision, a good Commander will explain the reasons for the choice to the rest of the crew. 15-4 © Oxtord Aviation Services LimitedHUMAN PERFORMANCE DECISION-MAKING AND RISK One further aspect of decision-making and risk is important, Sometimes there is a choice of only two actions, one a risk and the other a sure-thing. Man tends to make his decision dependant upon whether the problem is framed as a choice between two gains or two losses. People are biased to choose the risky loss rather than the certain loss, even when the expected Joss resulting from the Former is greater, Consider the pilot who must choose, for example, between turing back in the face of potentially bad weather (with the certainty of disappointing passengers and, perhaps, personal embarrassment), or continuing on (with the chance of getting through safely and on time but also with a chance of suffering a major disaster), The choice is clearly between two negatives : a sure loss against an uncertain possibility of a disaster. Research has found that people have a bias to favour the risky choice, Many, many pilots and passengers have died as a result of this bias (“press-on-itis”). Interestingly, this risk-seeking tendency is reversed when the choice is framed as one between gains. Here the sure-thing alternative is favoured. The really important point is that if our pilot could have framed his choice differently as a choice between two gains (the certainty of saving lives by turning back versus the possibility of not disappointing the passengers by continuing), he/she would have been biased to make the wiser decision. Assign Tasks. Workload is shared amoi 1 the crew by the assigning of tasks. It should not be forgotten that tasks may also be assigned to outside agencies (traffic information or diversion/holding of other aircraft by ATC). Implement Deci The Commander of the aircraft is responsible for supervising and monit implementation of his/her decision, n, Consequences, If the decision has been correct, the outcome of its implementation should be the Commander's original objective. If not, then either the decision is incorrect or the situation has changed, Review and Feedback. The situation is constantly changing in the air, Review of actions by the flight crew is fundamental and it should be on-going. If the situation has changed, then the Commander should check whether the outcome of his/her decision is still valid - if it is no longer valid, the whole process starts again from the beginning. Thus the real situation is thereby continually monitored 15-5 © Onford Aviation Services LimitedHUMAN PERFORMANCE DECISION-MAKING AND RISK 15.3 ERRORS AND SOURCES AND LIMITS IN THE DECISION-MAKING PROCESS. The Dec’ jjon-making process is prone to human error and may be limited by outside factors. ‘These are discussed in this paragraph. Errors @) b) ° d) f) Confirmation Bias. See Chapter 8, The best method to avoid this error is to deliberately look for information that will falsify the hypothesis rather than confirm it. Probability. ‘The pilot will be heavily influenced by the probability of an occurrence. For example aa bang heard on take off could be a tyre burst, a bird strike, or an engine failure. A. burst tyre is the most probable cause of a loud noise at this stage. Thus pilots may automatically carry out the initial drills for that event. Salieney. People often tend to focus attention most heavily on those cues that are physically salient (loud, bright, recent, centrally visible, easy to interpret), Thus vital non-salient information may be over-looked. Over-confidence. An over-confidence either of personal skill or decision-making ability have been the direct cause of many bad airborne decisions. A good aviator, however experienced, is the first to admit that there is always much to learn. Over-confidence breeds Complacency. Hand-in-hand with complaceney is the loss of motivation to practise or learn. Performance can only deteriorate. This is sometimes known as the “Deterioration Effect”. ‘The higher accident rate for general aviation pilots with between 1,000 and 3,000 flying hours, compared with those less experienced, is often explained by this Effect. Fatigue/overload. Both fatigue and overload will seriously affect decision-making. Denial A common aspect of human attitude when exposed to risk is that of denial. ‘This can typically manifest itself as one of the following behavioural patterns: i) Procrastination (“I'll continue to fly on for a little longer and then decide”. ii) Rationalisation (“I'll all work out just fine”). ili) Hope and desires (“It's bound to clear on the other side of these hills”). iv) Refusal to admit (“It’s not like that and anyway it can’t happen to me”). v) Status and reputation (“I'm just not going to be beaten”. vi) Refusal to review (“It worked last time in roughly the same situation”). Each of the above examples is a form of denial. It is a refusal to accept, admit, confront, change or decide and has been the cause of many accidents. It is fundamental that, in order for a good decision to be reached, the REAL situation is analysed, confronted and assessed. 15-6 © Oxford Aviation Sorvices LimitedHUMAN PERFORMANCE DECISION-MAKING AND RISK 15.5 15.6 Limitations, a) Attention, Human attention is limited or may be “funnelled” (perhaps due to stress) and thus input of information may be significantly curtailed. by As we have already seen, stress can have a dramatic effect on both the human body and mind. Decisions made under stress are rarely of high quality. ©) Lack of experience. Lack of experience will certainly slow down the decision-making process since diagnosis of the true situation will be slower than that of a skilled or an experienced pilot who will be able to rapidly correlate information from a number of sources because of the typical pattern that has been observed in the past In the same way, extensive fa particular aircraft malfunctions wil overall situati status. iarity with patterns of symptoms produced by iow the experienced pilot to rapiclly interpret the n from a potentially large number of cues indicating their individual PERSONALITY TRAITS AND EFFECTIVE CREW DECISION-MAKING The most important personality trait for effective crew decision-making is stability, JUDGEMENT CONCEPT Tt can be summarised that judgement, risk assessment and the consequential decision made in the air is based upon the: a) Pilot b) Aircraft c) Environmental conditions d) Time available COMMITMENT Commitment refers to the degree of commitment to a solution when making a decision and which represents the “point of no retu: 15-7 © Oxford Aviation Services LimitecHUMAN PERFORMANCE DECISION-MAKING AND RISK 6. CHAPTER 15 - REVISION QUESTIONS. What are the categories of risk ? a) Objective/Sudden and Subjective/Gradual b) —- Sudden/mpromptu and Gradual/Planned cc) External/Objective and Internal/Subjective d) Impromptu/Objective and Planned/Subjective The Commander is ultimately responsible for all decisions made in the cockpit : a) Tre b) False There is no difference between “deciding” and “decision-making” + a) True b) False A decision is “good” when : 2) It can be implemented within the available time b) ime is not an issue. The decision must be correct, ¢) Time can be an issue but the correct perception is the important factor When other members of the crew agree Preparation is essential for good decision-making when time is an issue : a) True b) False One of the possible problems of preparation is, a) Action Slip b) Confirmation Bias ©) Error of Commission d) Environment Capture If a person will tend to overestimate the frequency of : a) A common but negative occurrence b) A common but beneficial occurrence c) A rare but beneficial occurrence d) Aare but negative occurrence 15-8 © Osford Aviation Services LimitedHUMAN PERFORMANCE DECISION-MAKING AND RISK 10. 13. Negative events are tended to be overestimated when a) They are well published b) Obvious ©) Under published d) The results are unclear ‘The risk of an Airprox is normally a) Overestimated b) ——_ Underestimated ©) Discounted d) Accurately assessed Evaluation of options in the decision-making process involve a) Positive and negative considerations b) Values and costs ©) Planned and impromptu considerations d) Assigning tasks People tend to be biased to make a : a) _ Risky loss rather than a certain loss even if the expected loss from the former is greater b) Risky Joss rather than a certain loss even if the expected loss from the former is le c) _ Risky loss rather than a certain loss even if the expected loss from the latter is greater d) Risky loss rather than a certain loss even if the expected loss from the latter is far greater a) Common dilemma faced by all pilots b) Is only experienced by skilled pilots ©) Only happens to inexperienced pilots ad Is rarely faced by good pilots The co-pilot is responsible for monitoring the implementation of the Commander’s decision a) Te b) False 15-9 © Oxtord Aviation Services LimitedHUMAN PERFORMANCE DECISION-MAKING AND RISK 14. 15. 16. 18. People tend to focus on salient cues a) True b) False Fatigue/overload a) ies affects decision-making b) Rarely affects decision-making ©) Never affects decision-making d) Always affects decision-making In the decision-making process, what should follow “Review and feedback” ? a) Assign Tasks b) Decide ° isk assessment d) Diagnose and define objective Man is extremely capable of accurate risk a) True b) False Input from the crew is an important factor in the decision-making process : a) True b) False Lack of experience will have the following effect on the decision-making process : a) Will speed it up (leaping in at the deep end) b) Slow itdown ©) Have no effect 3) Disrupt the process ‘The decision process should include the erew : a) True b) False 15-10 © Oxtord Aviation Services Limitec