“are you sure about that?”old.annualghac.com/assets/pdf/day18ghac/01 - nicklas... · 2016. 10....
TRANSCRIPT
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“Are you sure about that?”– Understanding and Improving Decision Making
Dr. Nicklas Dahlstrom
Human Factors Manager
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Successful Operations
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Challenging Environment
Akobo Airport, 3 June 2016
Yambio Airport, 4 June 2016
Bor Airport, 12 May 2016
Bor Airport, 14 June 2016
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Making Decisions ina Challenging Environment
(WFP, 2015)
The main hazards identified in 2015
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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
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Understanding Decision Making
“The Moment of Choice”Too much focus on this,
not enough on the process
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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
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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
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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
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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
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Paris, 23-26 March 2015 21st Flight Safety Conference
Case Study: A320 from GAU to DEL
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Paris, 23-26 March 2015 21st Flight Safety Conference
Case Study: A320 from GAU to DEL
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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)
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Decision Making
Seconds Minutes HoursSplit-second
Fuel
Weather
Medical
TCAS
GPWS
Wind shear
Rational
decision
making
Conditioned
reaction ?
All other
decisions
Natural
decision
making
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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
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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 …
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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)
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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)
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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)
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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
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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
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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
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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
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From FO to Captain
(Fischer & Orasanu,
1995)
FOs: Time and
SOPs
Study - Priorities in scenarios:
Captains: Risk and Time
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Better Decisions= Safer and more Efficient Operations
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• 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
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The Vision