decisions, decisions….. naturalistic decision making

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Decisions, decisions….

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Page 1: Decisions, decisions….. Naturalistic Decision Making

Decisions, decisions….

Page 2: Decisions, decisions….. Naturalistic Decision Making

Naturalistic Decision Making

Page 3: Decisions, decisions….. Naturalistic Decision Making

How We Make Individual DecisionsWhy We Fail as Teams

• How do individuals make decisions?

• Do we look at possible alternatives, weigh cost:benefit of each, and then decide on a course

of action? OR• Do we search our minds for a pattern that fits the

situation, and apply the solution we remember?

Page 4: Decisions, decisions….. Naturalistic Decision Making

It Depends…..

• It is dictated by the situation and environment.

Page 5: Decisions, decisions….. Naturalistic Decision Making

The Matrix

Page 6: Decisions, decisions….. Naturalistic Decision Making

What do we want to accomplish?

Who’s Cooking?

• Price• Previous History• Clean-up• Taste

Fast Attack

• Rescue• Exposures• Water supply• Fire conditions

Page 7: Decisions, decisions….. Naturalistic Decision Making

Which vocation is like Firefighting?

• Engineer

• Consistent level of stress

• Comprehensive data set

• Computer modeling

• Static stressors

• Individual/ team focus

• Airline Pilot

• Hours of boredom, moments of sheer terror

• Limited data available

• Situational training

• Dynamic stressors

• Team/individual focus

Page 8: Decisions, decisions….. Naturalistic Decision Making

Top Gun

Page 9: Decisions, decisions….. Naturalistic Decision Making

Fireground commanders render decisions in environments like airline pilots, ambulance paramedics, military commanders, critical care/ED nurses and physicians, nuclear power plant operators, and air traffic controllers.

Environments in which the opportunities to evaluate alternatives is

limited.

Page 10: Decisions, decisions….. Naturalistic Decision Making

Sources of Power

Conventional

• Deductive, logical thinking

• Analysis of probabilities

• Statistical methods

In Natural Settings

• Intuition• Mental simulation• Metaphor• Storytelling

Page 11: Decisions, decisions….. Naturalistic Decision Making

Fireground commanders make decisions in natural settings

And hence, employ naturalistic decision-making as their predominant, individual

modus operandi

Page 12: Decisions, decisions….. Naturalistic Decision Making

The Fireground Problem Environment

• Unstructured, real-world problems• Complex-multiple signs and symptoms, often

interacting without cause/effect relationships or interdependent (with cause/effect)

• Dynamic• Almost always dangerous• Almost always distracting

Page 13: Decisions, decisions….. Naturalistic Decision Making

The Naturalistic Decision Making Environment

• Time pressure• High Stakes• Need for experienced decision-makers• Inadequate information• Ill-defined goals• Poorly defined procedures• Dynamic, contextual learning• Teamwork

Page 14: Decisions, decisions….. Naturalistic Decision Making

Naturalistic Decision-Making

• Recognition-primed (flour on the floor)

• Singular, as opposed to comparative evaluation. Considering options and immediately selecting the first reasonable one, as opposed to seeking the best option.

• Novices need to compare different options. Experienced personnel generate a single course of action

Page 15: Decisions, decisions….. Naturalistic Decision Making

We are interested in:• Time pressure

• High Stakes

• Gaining experience as decision makers

• Inadequate information

• Unclear Goals

• Poorly defined procedures

• Cue Learning

• Context

• Dynamic conditions

• Teamwork

Page 16: Decisions, decisions….. Naturalistic Decision Making

Classical Decision Analysis Method

• Identifies the set of options

• Identifies the way of evaluating those options

• Weights each evaluation dimension

• Does the rating

• Picks the option with the highest score

Page 17: Decisions, decisions….. Naturalistic Decision Making

We don’t have to evaluate options...

Let experience show you a model reaction to the situation. Even non-routine situations can be prototypes of past experiences that can be adapted quickly and successfully.

Page 18: Decisions, decisions….. Naturalistic Decision Making

Hit the Brakes

Page 19: Decisions, decisions….. Naturalistic Decision Making

….but we do have to have a second means of egress!

• Take in the whole picture, make your decision, act on it, then continually reevaluate the situation.

• Develop a backup plan for use if the situation changes.

• What can go wrong? The house is already on fire.

• The next one can light off!!

Page 20: Decisions, decisions….. Naturalistic Decision Making

CONSTRUCT PLAN B & C

• When you feel like you have a handle on where you want it to go…remember, Murphy (not John) takes command of some fires and plans B & C are always necessary.

Page 21: Decisions, decisions….. Naturalistic Decision Making

Making a decision error when the correct situation is comprehended vs. making a

decision error when the situation is incorrectly comprehended

SITUATIONAL AWARENESS

Page 22: Decisions, decisions….. Naturalistic Decision Making

Intuition

• Intuition depends on experience to recognize key patterns that indicate the dynamics of the situation.

• You must also recognize missing key patterns that indicate a different situation.

• ESP

• Sixth Sense

• (Basement fire/HMS Gloucester)

Page 23: Decisions, decisions….. Naturalistic Decision Making

Mental Simulations

• The ability to imagine people and objects consciously and to transform those people and objects through several transitions, finally picturing them in a different way than at the start.

Page 24: Decisions, decisions….. Naturalistic Decision Making

•Even though we don’t use the classical decision making model (comparing options against each other), we can quickly go through several options to find that option that is best suited to the situation.

•Use mental simulations

(auto extrication)

Page 25: Decisions, decisions….. Naturalistic Decision Making

•Don’t let mental simulations skew the facts or ignore the situation.

•Remember situational awareness

Page 26: Decisions, decisions….. Naturalistic Decision Making

A Whale of a Problem

Page 27: Decisions, decisions….. Naturalistic Decision Making

Mental Simulations:

• Let us explain how events have moved from the past into the present

• Let us project how the present will move into the future

• Construct an action sequence in which one state of affairs is transformed into another

• Because of memory limitations, people usually construct mental simulations using around three variables and six transitions

Page 28: Decisions, decisions….. Naturalistic Decision Making

Mental Simulations:

• It takes a fair amount of experience to construct a useful mental simulation

• Can run into trouble when too complicated, or when time pressure, noise, etc. interfere

• Can mislead when you argue away challenging evidence

Page 29: Decisions, decisions….. Naturalistic Decision Making

Storytelling

• Stories organize events into a meaningful framework

• They serve as natural experiments, linking a network of causes to their effects

• They are similar to mental simulations

• Stories can be used to extract and communicate subtle aspects of expertise

Page 30: Decisions, decisions….. Naturalistic Decision Making

Metaphors and Analogues

• Different situations, but similar in some way that will help us place it perspective

• Helps us see cause/effect relationships

• Helps us see value of risk/benefit analysis

Page 31: Decisions, decisions….. Naturalistic Decision Making

APOLLO 13

• A CASE STUDY IN PROBLEM SOLVING

• There were about five instances of goal revision. The most dramatic was the shift in goals from trying to continue the mission while repairing the problem, to calling off the mission and concentrating on the astronauts safe return home.

• Everyone must go home safely!!!

Page 32: Decisions, decisions….. Naturalistic Decision Making

Naturalistic Decision Making The Bottom Line

• People who repeatedly confront a particular task move in stages from the rank of novice, to that of expert.

• Leaders who are rated as superior explain to subordinates in clear language what they see, and how they want to react to changing circumstances.

• Subordinates’ input is then given due and STRONG consideration.

Page 33: Decisions, decisions….. Naturalistic Decision Making

What are our assets?

• Our minds and our memories

• Our bodies

• Limited diagnostic instrumentation

• Limited time

• Our collective minds

Page 34: Decisions, decisions….. Naturalistic Decision Making

Use your team

Learn to make decisions without technology

Page 35: Decisions, decisions….. Naturalistic Decision Making

The Team (crew)A collective of Minds

• A collection of minds is a limited resource

• A collective of minds create increased problem-solving capability

• How can we best manage our greatest resource….the crew?

Page 36: Decisions, decisions….. Naturalistic Decision Making

The word “management” may not be the most appropriate, but the process of optimizing the collective of minds for the good of the order is called:

CREW RESOURCE

MANAGEMENT

Page 37: Decisions, decisions….. Naturalistic Decision Making

THE BORG

Page 38: Decisions, decisions….. Naturalistic Decision Making

How many times have you seen:

• Competent, well-meaning officers

• Knowledgeable and caring

• Able to instantly trouble-shoot problems

• FAIL during complex events??

Page 39: Decisions, decisions….. Naturalistic Decision Making

It’s a Symphony

• Many individuals play their instruments well

• To play collectively, as a BAND, takes teamwork, coordination, communication, and leadership

• Active listening by players and director to know when to play

Page 40: Decisions, decisions….. Naturalistic Decision Making

Our Acceptance of Adverse Effects

• % of Arlington Firefighters are injured every year.

• 112 firefighters died last year across the nation

• But… we’re good at funerals

• If commercial air travel had even a 0.1% major accident rate, it would result in 2 airliner crashes every three days….

Page 41: Decisions, decisions….. Naturalistic Decision Making

Everything is relative

• A firefighter dies and the newspapers say it is tragic.

• An airplane crashes and it is a disaster.

• THEY ARE BOTH DISASTERS

Page 42: Decisions, decisions….. Naturalistic Decision Making

Examples of Individual Success in the Fire Service

• “Downstream” thinking: Commonly used by “experts”

• Initial placement of truck companies, use of a RIC, aggressive exposure protection, plan B & C

Page 43: Decisions, decisions….. Naturalistic Decision Making

Examples of Team Success

• Multi-alarm fires

• Mass-casualty Events

• Hazardous Materials Incidents

• Complex scene management

• Natural Disasters

• Man-made disasters

Page 44: Decisions, decisions….. Naturalistic Decision Making

Crew Resource Management(CRM)

• Development prompted by UAL DC-8 crash close to Portland in 1978

• 70% of airline accidents involve some degree of human error

• Most human error is not isolated, but is a result of dysfunctional teamwork

• CRM is grounded in social, cognitive, and organizational psychology

Page 45: Decisions, decisions….. Naturalistic Decision Making

The most effective use of the collective of minds is grounded in

Interpersonal Communication

Page 46: Decisions, decisions….. Naturalistic Decision Making

The United Air Crash Lesson

• Cockpit voice recorder excerpts…contributing factors:

• Critical interruptions• Incomplete thoughts, not validated• Subtle intimidation (rank structure)• “Junior” crew member failure to verbalize

concerns appropriately• Did not use the Team effectively

Page 47: Decisions, decisions….. Naturalistic Decision Making

The Cast

• FA (Flight Attendant)

• McBroom- Pilot and One of United’s most senior, experienced captains

• Frostie- (Mendenhall)Flight engineer

• AC- Air traffic controller

• Beebe-First Officer

Page 48: Decisions, decisions….. Naturalistic Decision Making

5:44 PM

• FA- I’ll be honest with you, I’ve never had one of these before, my first you know…

• McBroom- All right, what we’ll do is have Frostie, oh about a couple of minutes before touchdown signal for brace position…

• Failure-didn’t acknowledge the attendant’s anxiety

Page 49: Decisions, decisions….. Naturalistic Decision Making

5:50 PM• McBroom-Give us a current card on the weight

figure about another 15 minutes…• Mendenhall- Fifteen minutes?• McBroom-yeah, give us three or four hundred

pounds on top of zero fuel weight• Mendenhall-Not enough….• Beebe-Fifteen minutes is gonna really run us low

on fuel here…• AC-United 173 heavy, left turn heading 0-5-0...

Page 50: Decisions, decisions….. Naturalistic Decision Making

5:50 PM• Beebe-OK, left zero-five-zero

• AC- United 173 heavy, clear of first traffic, now there’s one at…

• Failure #1

• Failure #2

• Failure #3

Page 51: Decisions, decisions….. Naturalistic Decision Making

Making a decision error when the correct situation is comprehended vs. making a

decision error when the situation is incorrectly comprehended

SITUATIONAL AWARENESS

Page 52: Decisions, decisions….. Naturalistic Decision Making

6:01 PM

• AC- Did you figure anything out yet about how much longer?

• Beebe- ….It’ll be our intention to land in about five minutes on two-eight left, we would like all the equipment standing by…

• Time:6:01:06PM

Page 53: Decisions, decisions….. Naturalistic Decision Making

6:03PM

• McBroom- Very well, they’ve about finished in the cabin…I’d guess about another three, four, five minutes…

• AC-United 173 heavy, give us souls on board and amount of fuel

• McBroom-One seven two and about 4 thousand, well make it three thousand pounds of fuel

Page 54: Decisions, decisions….. Naturalistic Decision Making

McBroom

• Hard man in cockpit to deal with

• Failure #4

• Failure #5

• Failure #6

• Similarities in air ambulance crashes also

Page 55: Decisions, decisions….. Naturalistic Decision Making

6:04PM• McBroom- OK, we’re going to go in now, we should

be landing in about five minutes.• Beebe-I think you just lost number four buddy, you…• FA-OK, I’ll make the five minute announcement, I’ll

go, I’m sitting down now…• Beebe- Better get the crossfeeds open!• Mendenhall- OK• FA-All righty• Failure #7

Page 56: Decisions, decisions….. Naturalistic Decision Making

6:04PM• Beebe- We’re losing an engine, buddy

• McBroom- Why?

• Beebe- We’re losing an engine

• McBroom- Why?

• Beebe- Fuel

• Beebe- Open the crossfeeds, man!

• McBroom-Open the crossfeeds there or something…

• Mendenhall- Showing fumes, guys...

Page 57: Decisions, decisions….. Naturalistic Decision Making

6:04PM• McBroom- Showing a thousand or better…

• Beebe- I don’t think it’s in there…

• Mendenhall- Showing three thousand, isn’t it?

• Failure #8

• Failure #9

• Failure #10

Page 58: Decisions, decisions….. Naturalistic Decision Making

Relation to Fireground

• During critical incidents, when tactics are suffering, we try to solve the problem rather than dealing with the immediate issues.

• Just fly the plane

Page 59: Decisions, decisions….. Naturalistic Decision Making

6:07PM• Beebe- It’s flamed out…• McBroom(radio) United 173 heavy would like a

clearance for an approach into two-eight left, NOW• Mendenhall- We’re going to lose number three in a

minute, too.• McBroom- Very well.• Mendenhall- It’s showing zero.• McBroom- You got a thousand, you got two!

Page 60: Decisions, decisions….. Naturalistic Decision Making

6:12PM• Beebe- Let’s take the shortest route to the airport.

• McBroom-(to AC) What’s our distance now?

• AC- Twelve flying miles.

• (?)- Well, (deleted)

• McBroom- About three minutes, Four

• Mendenhall- We’ve lost two more engines, guys…

• Failure # 11

• Failure # 12

Page 61: Decisions, decisions….. Naturalistic Decision Making

6:13PM (plus 23 minutes)• AC- Have a good one!• McBroom- They’re all going…• McBroom- We can’t make Troutdale…• Beebe- We can’t make anything…• McBroom- OK, declare a Mayday• Beebe- Portland tower, United 173 heavy. Mayday,

mayday, we’re…the engines are flamming out, we’re going down, we’re not going to make the airport.

• Tower- United one-seven…(sounds of impact)

Page 62: Decisions, decisions….. Naturalistic Decision Making

United’s Success Story

• Sioux City, Iowa crash, 1989 (11 years later)• On the cockpit tape, there was a direct relationship

between Commands, Verbal Acknowledgements, Observations, and Inquiries.

• Situational Awareness

Page 63: Decisions, decisions….. Naturalistic Decision Making

The Cornerstones of CRM as taught by the FAA

• Situational Awareness

• Information gathering

• Frankly stated opinions

• Dispute resolution

• Decision Making

• Constructive criticism

Page 64: Decisions, decisions….. Naturalistic Decision Making

One absolute way to facilitate communication...

• Abdicate your power or authority

• Leave hats and badges at the door

• Shuck your ego or it will kill you…or others

• Ask for help when you need it

Page 65: Decisions, decisions….. Naturalistic Decision Making

Why did Sioux City succeed?

• Pilot recognized he needed help and asked

• Great communication

• Realized their plight and reacted accordingly

• Simulation given to other pilots

Page 66: Decisions, decisions….. Naturalistic Decision Making

RPD model claims that with experienced decision makers:

• The focus is on the way they assess the situation and judge it familiar, not on comparing options.

• Courses of action can be quickly evaluated by imagining how they will be carried out, not by formal analysis and/or comparison.

• Decision makers usually look for the workable option they can find, not the best option.

Page 67: Decisions, decisions….. Naturalistic Decision Making

With experienced decision makers:

• Since the first option they consider is usually workable, they do not have to generate a large set of options to be sure they get a good one.

• They generate and evaluate options one at a time and do not bother comparing the advantages and disadvantages of alternatives.

Page 68: Decisions, decisions….. Naturalistic Decision Making

By imagining the option being carried out, they can spot weaknesses and find ways to avoid these, thereby making the option stronger. Conventional models just select the best, without seeing how it can be improved.

Page 69: Decisions, decisions….. Naturalistic Decision Making

Finally….

• The emphasis is on being poised to act rather than being paralyzed until all the evaluations have been completed….and the party is over.

Page 70: Decisions, decisions….. Naturalistic Decision Making

RECOGNIZE THIS FACT

• The most important moments in life:

• Are those brief moments between the stimulus and your response…

• Only YOU have control over your response...

Page 71: Decisions, decisions….. Naturalistic Decision Making

Let’s understand ourselves...

• Many of us like to control situations and people

• We are externally driven

• We like to see results quickly

• We are individualists

Page 72: Decisions, decisions….. Naturalistic Decision Making

Individualists

• Value independence and self-sufficiency, prefer individual achievement

• Self-reliance is a strength, seeking help implies weakness

• Mistakes are evaluated by personal standards• May be associated with higher crime rates,

suicide, and stress-related diseases

Page 73: Decisions, decisions….. Naturalistic Decision Making

Summary

• WITH EXPERIENCED DECISION MAKERS:

• The focus is on the way you assess the situation and judge it familiar, not on comparing options.

• Courses of action can be quickly evaluated by imagining how the will be carried out, not by formal analysis and comparisons

Page 74: Decisions, decisions….. Naturalistic Decision Making

Summary• They usually work for the first workable options

they can find, not the best option.

• The first option is usually workable.

• They generate and evaluate options one at a time, not comparing alternatives.

• By imagining the option being carried out, they can spot weaknesses and find ways to avoid them, making the option stronger.

• Be poised to act, not paralyzed by analysis.

Page 75: Decisions, decisions….. Naturalistic Decision Making

Summary

• Understand how you individually solve problems.

• Remind yourself that collective experience is a shared resource.

• Remember that communicating effectively is the key.

• The confident officer is not afraid to ask for the opinions or assistance of others.

Page 76: Decisions, decisions….. Naturalistic Decision Making

Experienced Officers Learn By:

• Deliberate practice, each opportunity has a goal and evaluation criteria

• Compiling an extensive experience bank

• Obtaining feedback that is accurate, diagnostic, and timely

• Reviewing prior experiences of self and others to gain new insights and lessons from mistakes.