Decisions, decisions….
Naturalistic Decision Making
How We Make Individual Decisions
Why 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?
It Depends…..
• It is dictated by the situation and
environment.
The Matrix
What do we want to accomplish?
Who’s Cooking?
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Price
Previous History
Clean-up
Taste
Fast Attack
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Rescue
Exposures
Water supply
Fire conditions
Which vocation is like
Firefighting?
• Engineer
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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
Top Gun
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.
Sources of Power
Conventional
• Deductive, logical
thinking
• Analysis of
probabilities
• Statistical methods
In Natural Settings
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Intuition
Mental simulation
Metaphor
Storytelling
Fireground commanders make decisions in
natural settings
And hence, employ naturalistic decision-making as their
predominant, individual
modus operandi
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
The Naturalistic Decision
Making Environment
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Time pressure
High Stakes
Need for experienced decision-makers
Inadequate information
Ill-defined goals
Poorly defined procedures
Dynamic, contextual learning
Teamwork
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
We are interested in:
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Time pressure
High Stakes
Gaining experience as decision makers
Inadequate information
Unclear Goals
Poorly defined procedures
Cue Learning
Context
Dynamic conditions
Teamwork
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
We don’t have to evaluate
options...
Let experience show you a model
reaction to the situation. Even nonroutine situations can be prototypes
of past experiences that can be
adapted quickly and successfully.
Hit the Brakes
….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!!
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.
Making a decision error when the correct
situation is comprehended vs. making a
decision error when the situation is
incorrectly comprehended
SITUATIONAL AWARENESS
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)
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.
•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)
•Don’t let mental simulations skew
the facts or ignore the situation.
•Remember situational awareness
A Whale of a Problem
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
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
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
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
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!!!
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.
What are our assets?
• Our minds and our memories
• Our bodies
• Limited diagnostic instrumentation
• Limited time
• Our collective minds
Use your team
Learn to make decisions without
technology
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?
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
THE BORG
How many times have you seen:
• Competent, well-meaning officers
• Knowledgeable and caring
• Able to instantly trouble-shoot problems
• FAIL during complex events??
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
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….
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
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
Examples of Team Success
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Multi-alarm fires
Mass-casualty Events
Hazardous Materials Incidents
Complex scene management
Natural Disasters
Man-made disasters
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
The most effective use of the
collective of minds is grounded in
Interpersonal
Communication
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
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
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
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...
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
Making a decision error when the correct
situation is comprehended vs. making a
decision error when the situation is
incorrectly comprehended
SITUATIONAL AWARENESS
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
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
McBroom
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Hard man in cockpit to deal with
Failure #4
Failure #5
Failure #6
• Similarities in air ambulance crashes also
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
6:04PM
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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...
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
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
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!
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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
6:13PM (plus 23 minutes)
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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)
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
The Cornerstones of CRM as
taught by the FAA
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Situational Awareness
Information gathering
Frankly stated opinions
Dispute resolution
Decision Making
Constructive criticism
One absolute way to facilitate
communication...
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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
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
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.
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.
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.
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.
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...
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
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
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
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.
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.
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.