MODULE 10

DECISION MAKING

Table of Contents

Session plan ........................................................................................................................ 2

Decision making ................................................................................................................ 3
Importance of effective decision making ................................................................. 3
Defining decision making .......................................................................................... 4
Team decisions................................................................................................................... 5
Defective decision making ............................................................................................... 7
Mistakes versus bad decisions ................................................................................. 7
Decision making traps ............................................................................................... 7
Barriers to good decision making ............................................................................. 8
Recognising poor decisions .............................................................................................. 8
Hazardous attitudes......................................................................................................... 10
Decision-making vs. risk management .................................................................. 12
Structured decision-making .................................................................................... 12
Defective decision-making ...................................................................................... 13
Recognition of poor judgement ............................................................................... 13
Factors which promote good decision making ........................................................... 14
Decision making tool - DODAR ...................................................................................... 15
Decision making tool - DECIDE ...................................................................................... 16
Flying for the wrong reasons .......................................................................................... 16
Review of the key points to effective decision making. ............................................ 18
References ........................................................................................................................ 18

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Module 10

Decision Making

Session plan

Module no 10

Module title Decision making

Duration 1 hour 30 mins

Optimal class size 6 to 12

Learning On completion of this module the student will understand:

Objectives
Be aware of the decision making process, identify the factors which can lead to
defective decision making and those which contribute to effective decision making.

Delivery method Facilitation

Trainer Trainer to have completed 5 day CRM Trainer core course.

qualifications

Student None
prerequisites

Trainer materials PowerPoint

Whiteboard
Flipchart

Participant Handout: N/A

materials

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Decision making
Slide – Header slide

Slide – Decision making

Importance of effective decision making

In order to perform effectively in our jobs we need physical skills and knowledge, but even
if we have these essentials, defective decision making can still get us in to trouble.

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Defining decision making

Question

What is a decision?

Slide – What is a decision?

Decision making is the process of making up your mind to pursue a course of action.
Making sound decisions is a skill set that we can develop like any other. When we make a
poor decision, it’s not that we aren’t capable of making the correct decision, but for
whatever reason we fail to use a sound approach to making the decision.
Gut instincts can take you so far in life, and anyone who operates outside of a sound
decision making framework will eventually fall prey to an act of oversight, misinformation,
misunderstanding, manipulation, impulsivity or some other negative factor.
Everyday life is full of decisions. Many are so simple that we don’t notice making them.
Others are more difficult or more complex. We can break down in detail the steps in the
decision making process.
Decision making is the process of making up your mind to pursue a course of action.
Effective decision making refers to the ability to choose a course of action using logical
and sound judgement to make decisions based on available information. This includes:

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Slide – Decision making process

Team decisions
If the best decision is to be made in a team environment, the team leader should use
effective management principals. It is important to recognise that eliciting the views of
team members does not show weakness on behalf of the team leader, rather the opposite
is true. Neither does it mean that the final decision is a democratic process.

Slide – Team decisions

It will usually be the case that the team leader will have ultimate responsibility for the
decision that is made. Using sound principles will allow the decision to benefit from the
experience, knowledge and situational awareness of all the team members and will also
contribute to the morale of the team and the personal development of the team members.
When the team leader has made a decision, the reasons for arriving at that decision
should be explained if there is time. Failure to do so will make the team members feel that
their ideas have been ignored; with the result that in the future they will be less inclined to
put forward proposals.

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Slide – Contributing to decision making in teams

Other guidelines that are appropriate for all team members are:
 Don't delay airing uncertainties or anxieties because you think you
might appear foolish or weak. Others may well have the same doubts
and will welcome some openness. There is no such thing as a stupid
question when it comes to safety!
 When asked, give your point of view fully and clearly.
 Do not worry about whether you are saying what the others want to
hear.
 Don't give opinions in an emotionally or dominant way e.g. “any fool
can see that”. Do not become “ego involved” with your own point of
view and determined to get your own way.
 If a group decision has been made, accept it, unless you feel it contains
some hazard not appreciated by the other group members.
 Do not let others progress down wrong paths of action and into trouble,
just to make yourself look clever.
 Don't compete, don't get angry, don't shout and don't sulk. Do not let
your own bad mood show. Try to maintain a pleasant working
atmosphere.
Abrasive tones do not promote co-operation or teamwork. Likewise sarcasm, bullying or
the scoring of points do nothing to improve relationships. Approachability in your job is
vital. If you portray the image that you are unapproachable, people will be reluctant to ask
you questions if they are unsure of a procedure or perhaps even question an error you may
make. A pre-requisite of good management and leadership is the ability to properly
communicate with others. Encouragement must also be given to others to communicate
freely without fear or embarrassment. A good manager should at all times be receptive to
the views of others.

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Defective decision making

There is a saying “Everything happens for a reason”. But sometimes the reason is that you
have made a bad decision!
There are two basic principles that often emerge in the analysis of mishaps that are
caused by defective decision-making:
 One bad decision often leads to another in a "snowball" effect.
 A series of bad decisions reduces the alternatives for continued safe
practices. As time goes by, available alternatives decrease.
Decisions are based on information the team member has about all the variables dealing
with systems, the environment, operations and other personnel. A poor judgement is less
likely to be made if this information is accurate.
However, every poor judgement made increases the availability of false data, which may
then negatively influence judgements that follow. As the poor judgement chain grows,
situational awareness becomes more impaired and the alternatives decrease. If a poor
alternative is selected, the chance to select other options may be lost.

Mistakes versus bad decisions

A politician cheats on his wife, gets caught, and says he “made a big mistake.” A
business person purposely omits some revenue on their tax return and says something
similar to the Inland Revenue. In truth, these examples aren’t mistakes, they’re bad
decisions.
Selecting the wrong answer on a test is a mistake. Not studying for that test is a bad
decision. The mistake was something you did without intention, while the bad decision was
made intentionally, often without regard for the consequence.
It’s easy to dismiss your bad decisions by reclassifying them as mistakes. It takes the edge
off, softens the blow. But it’s worse than that: reclassifying a bad decision as a mistake
removes your sense of responsibility, making it no longer your fault. And it’s a lot easier to
live with your bad decisions if they aren’t your fault. Consequently, you’re more likely to
make the same bad decision over and over and over again if you simply consider it a
mistake.
We all make mistakes. We all make bad decisions. They are part of the human experience.
We can sometimes celebrate our mistakes as failure is occasionally the key to success.
And we can learn from our bad decisions. But let’s not confuse one with the other.

Decision making traps

Question

What are the traps we may fall into when making decisions?

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Slide – Decision making traps

Barriers to good decision making

Facilitate a discussion to elicit from the participants the barriers to good decision making,
capture on the whiteboard or flipchart.
Compare to following slide

Slide – Barriers to good decision making

Conventional wisdom used to hold, that judgment was something you were born with, it
couldn't be taught. Although judgment is difficult to put into concrete terms, the elements
that go to make up decision-making can be taught to enable the student to render
decisions in a rational manner, even under stressful conditions and high workload.
Also the importance of the negative effect of personal attitudes on the ability to make wise
judgments can be recognised.

Recognising poor decisions

We know that poor decisions often lead to further poor decisions in a snowball effect, and
possibly to an incident or accident. We need to recognise when a poor decision has been
made and admit the error, or point it out to a superior. If we fail to recognise a poor
decision, the ability to prevent further poor decisions is reduced. Tools we can use to aid
the early recognition of poor decisions are:

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 Feedback
To recognise poor judgement, feedback is needed. Asking another
employee for feedback may be difficult because one may be hesitant to
admit an error in judgement. Yet relevant feedback is necessary in
order to break the chain quickly.
 Be aware of stress
A high level of stress can reduce the ability to exercise good judgement.
An awareness of colleagues’ stress levels and self awareness of each
of their own stress is necessary to good decisions.
 Challenge
Identify hazardous situations resulting from poor judgements and
rectify.
 Identify
Identify other poor decisions. Poor decisions tend to occur in chains. If
a poor decision is recognised, others may be present.
 Review
After the poor judgement chain has been broken; a review of the
original bad decision should be made as soon as possible. This review
will provide feedback to avoid similar, poor judgement chains in the
future.

Slide – Changing a decision

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Hazardous attitudes
There are a number of hazardous attitudes and behaviours that impede good judgement
and effective decision making. Even the most experienced and capable employees are
susceptible to such attitudes and they are embedded in all of us in one form or another.

Slide – Hazardous attitudes - 1

Slide – Hazardous attitudes - 2

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Hazardous Attitude Antidote

1 Anti-authority Follow the rules as they have been

"Don't tell me what to do." They often consider the rules developed with the benefit of years of
and regulations as unnecessary. experience from others.

2 The Impulsive attitude Step back, slow down and give it some
"Do something fast!". This is seen in people who feel the thought.
need to do something and do something now, they do not
stop to think for example, they may say; “lets get this job
done now, we don’t need to check the books or check with
the supervisor.” These people also jump to conclusions
and solutions. Beware of choosing a mental model of the
situation which seems close enough and then bending the
facts to fit the model.

3 Invulnerability, complacency, denial Make no mistake it could happen to

"It can't happen to me." This refers to those people who you.
feel that accidents only happen to others, crew who think
this are more likely to take unwise risks for example
signing off the snag you know you shouldn’t. Or, take for
example this very famous dialogue:
“When anyone asks me how I can best describe my
experience in nearly 40yrs at sea, I merely say uneventful.
Of course there have been winter gales, and storms and
fog and the like. But in all my experience, I have never
been in any accident, of any sort, worth speaking about. I
have seen but one vessel in distress in all my years at sea.
I never saw a wreck and never have been wrecked, nor
was I ever in any predicament that threatened to end in
disaster of any sort.”
Spoken by Edward J Smith, Captain of RMS Titanic 5th April
1912. On the 14th April 1912 RMS Titanic struck an
iceberg at 23:40hrs and sank with the loss of 1513 lives.

4 Macho "Can Do" attitude Not to take unnecessary risks, it

Risk taking to prove themselves or impress others. Being impresses no-one.
afraid to voice and share uncertainty or overload.

5 Resignation Remind yourself it is not what luck

"What's the use? Nothing I do makes any difference." They does to you that matters, it’s what you
have a reliance on luck for good or bad outcomes and can do in spite of what “luck” throws your
adopt a “someone is out to get me” attitude for a bad way.
outcome.

6 Not being willing to challenge ‘Experts’ If in doubt speak up. Remember the
Having many older, senior, ‘expert’ crew can exacerbate past has proved that even the most
this. highly regarded, experienced crew
make mistakes!

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Hazardous Attitude Antidote

7 Press on itis Can be found in the term “better late

Most crew will be familiar with this behaviour (perhaps than never”.
seen it on occasion) and it is a very powerful force. It is the
overriding need just to get the job done at any cost and it
blocks situational awareness and good decision making.

8 Risky shift The first stage to overcoming this

This is the concept that groups can make riskier decisions. hazardous behaviour is to recognise it
Decision making by a group tends to be of a higher quality in ourselves and others.
than the individual over a range of decisions and this gives
rise to the concept of synergy (1+1=3). However, research
has shown that groups can make riskier decisions than the
individual would make on their own. For example it is more
likely a group of kids would be more likely to climb over the
fence to steal apples or knock on a neighbour’s door and
then run away, than an individual child on their own. It
could be suggested that this phenomenon could be
explained that by being part of the group, you dilute both
the responsibility for and the guilt associated with taking a
high risk decision.

9 Anchoring bias While the past may be relevant, the

A decision based on an initial parameter (perhaps drawn environment may offer other pertinent
from memory or experience). It is the common human clues to the future. Illuminating
tendency to rely too heavily on the first piece of potential anchoring biases may enable
information offered (the "anchor") when making decisions. decision-makers to consider what
For example, the initial price offered for a used car sets the information they are considering
standard for the rest of the negotiations, so that prices
lower than the initial price seem more reasonable even if
they are still higher than what the car is really worth. Or,
I’ve been walking on the upper surface of aircraft without a
harness for 10 years and never slipped.

Decision-making vs. risk management

Judgment and decision-making must involve the assessment of risk. Risk management is
an ongoing evolution; it starts when we come to work and continues throughout the shift.
If risks aren't properly assessed, good judgments and decisions won't be made.
Judgment is the total mental process used to arrive at a decision.
Decision-making is the process of identifying a problem, gathering data, and using sound
judgment to reach a logical conclusion in a timely manner.
Risk management is an individual measure for an acceptable outcome to a given decision
or judgment.

Structured decision-making
The decision-making process is a synthesis of the elements of good CRM and situational
awareness. It involves an interface among communication, situational awareness and
authority. In defining decision-making in terms of CRM, all the resources available to the

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crew are pulled together to achieve synergy. Synergy is easier to achieve in an

environment of good communications and leadership.

Defective decision-making
There are two basic principles that emerge in the analysis of aircraft mishaps that are
caused by defective decision-making:
 One bad decision often leads to another in a "snowball" effect.
 A series of bad decisions reduces the alternatives for continued safe
practices. As time goes by, available alternatives decrease.
Decisions are based on information the crew member has about situational variables
dealing with the aircraft, the environment, operations and other crew members.
A poor judgement is less likely to be made if this information is accurate. However, every
poor judgement made increases the availability of false data, which may then negatively
influence judgements that follow. As the poor judgement chain grows, the crew member’s
situational awareness becomes more impaired and the alternatives decrease. If a poor
alternative is selected, the chance to select other options may be lost.

Recognition of poor judgement

The crew must recognise when a poor decision has been made and admit the error. If
recognition does not occur, the ability of the crew member to prevent further poor
judgements is reduced.
 Feedback: To recognise poor judgement, feedback is needed. Asking
another crew member for feedback may be difficult because one may
be hesitant to admit an error in judgement. Yet relevant feedback is
necessary in order to break the poor judgement chain quickly.
 Stress: A high level of stress can reduce the ability of a crew member to
exercise good judgement. An awareness of colleagues’ stress levels
and self awareness of each of their own stress is necessary to good
decisions.
 Challenge: Identify hazardous situations resulting from poor
judgements and rectify.
 Identify: Identify other poor decisions. Poor decisions tend to occur in
chains. If a poor decision affecting the safe operation of an aircraft is
recognised, others may be present.
 Review: After the poor judgement chain has been broken; a review of
the original bad decision should be made as soon as possible. This
review will provide feedback to avoid similar, poor judgement chains in
the future.

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Factors which promote good decision making

Slide – Factors which promote good decision making

Factors that promote structured decision making can be taught to enable the individual to
render decisions in a methodical manner even under stressful conditions and high
workload. The decision-making process is a synthesis of the elements of good CRM and
situational awareness. It involves an interface among communication, situational
awareness and authority. Factors which promote good decision-making:
 Teamwork.
 Extra time to make a decision.
 Alert colleagues.
 Sound decision strategies and experience.
 Risk Assessment - Risk management is an ongoing evolution; it starts
when we come to work and continues throughout the flight. If risks
aren't properly assessed, good judgments and decisions won't be
made.
 Inquiry – this is the process of gathering information. Let’s say that we
wanted to go to the pub. Among other things, we would want to know
what pubs are in the area and how we are going to get there. Ask
questions, collect and validate data, continuously update information.
 Advocacy is about stating your position or advocating a course of action.
Using the pub analogy, one person might say that he wanted to go to the
‘Black Swan’ and another might want to go to the ‘Royal Oak’ because
the beer is better. Frankly state opinions, express concerns, seek ideas
of others and test for accuracy.
Team members should speak up with appropriate persistence to resolve the problem. All
staff should be encouraged to state recommendations, you should assess the information
you have, ask questions and test assumptions.
Never hesitate to challenge, enquire or express concern. Use strong words such as: “I’m
not happy” or “I’m concerned” or “I’m uncomfortable”. This should alert the team to
rethink the situation.

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Decision making tool - DODAR

To assist with the decision making process you should try to remember the acronym
DODAR

Slide - DODAR

Diagnose
Make a diagnosis. Utilise all available resources and view differing opinions as being
helpful and not a hindrance.
Options
Work out what your options are. Encourage all team members to express opinions and air
their doubts or objections, without fear of being made to look foolish.
Decision
Make the decision. Always explain the reasons for a particular decision and deal only with
the facts.
Do not be indecisive but remember that any decision may be modified in the light of
changing circumstances.
Assign
Allocate the tasks and share the workload.
Review
Keep reviewing the decision at intervals. Remember, there are occasions where the group
decision is worse (the Risky Shift concept).

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Decision making tool - DECIDE

Another acronym is DECIDE

Detect a change
A change in the aircraft, environment or ‘gut’ is experienced.
Estimate significance
The significance of the change on the flight operation.
Choose outcome
Select the desired outcome.
Identify options
Options for actions or no action.
Do
Act on the best option.
Evaluate
The effect of the chosen action.

There are many other acronyms which provide a tool to assist with the decision making
process.

Flying for the wrong reasons

The following is an extract from Business & Commercial Aviation, May 31, 2002.
Pressured to perform: Flying for the wrong reasons, by Robert N. Rossier
We like to think that we have good judgment, and that regardless of the situation, we will
always make the right call. We train, we practice, and we follow the SOPs. We use the
checklists and follow the rules. But despite experience and professionalism, flight crews
still get themselves into trouble -- sometimes deep trouble.
We had just finished up a night of scheduled flying when the call came in; a woman on
Block Island had suffered life-threatening injuries in an accident and required immediate
transport to a hospital in Providence, R.I. After explaining the situation, the director of
operations asked if we could do the charter.
The conditions on Block Island were at minimums with gusty winds, rain and fog, but
considering the circumstances, the captain and I decided that we would give it a try. After
all, both our home airport and the destination -- Providence -- were well above minimums,
so we rationalised that we had an easy out if the conditions at Block Island precluded a
landing.
On the first approach to Runway 10, we saw absolutely nothing. The captain called
"missed approach," and I pushed the throttles forward. The missed-approach procedure
set us up for an approach to Runway 28, so we decided to give that a try. Nearing the

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missed-approach point, the runway lights blinked through the fog and drizzle. We began
our circling manoeuvre to Runway 10.
Battered by the winds, I felt more like a wrestler than a pilot. As we circled beneath the
ragged ceiling, we momentarily lost sight of the runway, but before I could push the
throttles up, it was in sight again. The bucking bronco ride from downwind to final was
enough to induce vertigo in good conditions. But within minutes, we were safely on the
ground, helping emergency medical personnel board our injured passenger.
The flight to Providence was uneventful, and thanks to ATC's help and a quick intercept to
the ILS/DME 34 approach, we were on the ground in half an hour. An ambulance and
medical crew were waiting for us as we taxied to the ramp.
On the flight home, I pondered our actions. We had safely transported a woman in
desperate need of medical attention -- that much was true. And from that perspective, it
was easy to justify our taking the flight. Everything was done according to FARs and
company regulations, but had anything gone wrong, our judgment certainly would have
been called into question. Investigators would have pinned any resulting accident on pilot
error, with fatigue, low visibility and wind shear as contributing factors.
What caused the Captain and I to accept the flight was the circumstance surrounding the
flight -- a person in serious medical need. If it had been some guy who wanted to get to the
casino, we wouldn't have considered making the flight. Our rationale would have been,
"Why risk our lives for someone who just wants to gamble away his fortune?" But when
framed in the context of a life and death situation on the part of the passenger, suddenly
we didn't see it as risking our lives. Without a doubt, we had allowed our emotions to enter
the decision making picture.
While these specific emotional pressures are perhaps uncommon for most commuters
and corporate or charter flight operations, they can be daily occurrences among air
ambulance operations. The emotional aspects of the mission often create a strong
pressure to conduct a flight, even in marginal conditions.
"Whether it's a sick passenger or a bag of rocks, we should be flying the same and making
the same decisions, but if the pilot has a 10-year-old son, and hears that it's a 10-year-old
boy who's been injured in the town next to his, there's going to be a part of him that wants
to fly that mission no matter what."
"One way we take the pressure off is to leave out the details of the mission, give the pilots
only the locations, and let them make the go/no-go decision. If they decide to take the
mission, we can give them the details once they're in the air."
While the particulars are different, a similar pressure can exist in the corporate flight
environment. A perceived need to get somewhere can add a level of urgency that tends to
override the typical decision making process.
The pressure to fly can come in any number of forms, from any number of sources.
Employers, passengers, personal perceptions and extenuating circumstances can conspire
to undermine our judgment. And as corporations strive to maintain schedules, contain
costs, and assess the value of all operations, flight departments may feel a heightened
need to deliver. But when pilots find themselves pressured to perform, there's a chance
that good judgment and safety will be compromised.

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Again, by separating the aviation decision making from outside influences, pilots are more
likely to make the right call and avoid the psychological

Review of the key points to effective decision making.

.Slide – Key points

.Slide – Questions

References
1) Risk and Decisions
2) W.T. Singleton & J. Hovden (1987). John Wiley & Sons.
3) Decision making in action: Models and methods
4) G. Klein, J .Orasanu, R. Calderwood & C. Zsambok (Eds.) Ablex.
5) A Review of Flightcrew-Involved, Major Accidents of U.S. Air Carriers,
1978 through 1990
6) National Transportation Safety Board. (1994).. (PB94-917001,
NTSB/SS-94/01).
7) Decision Errors in the Cockpit
8) Orasanu, J., Dismukes, K. & Fischer, U. (1993).. In Proceedings of the
Human Factors and Ergonomics Society 37th Annual Meeting

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