Presentation Transcript

1. Naturalistic Decision Making

   Decisions, Decisions….
2. 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?
3. It Depends….. It is dictated by the situation and environment.
4. The Matrix
5. What do we want to accomplish? Who’s Cooking Dinner? We Look At… Price Previous Cooking History Clean-up Taste Fast Attack or SAR? Rescue Exposures Water supply Fire conditions
6. 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
7. 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.
8. Decision Making Conventional Deductive, logical thinking Analysis of probabilities Statistical methods In Natural Settings Intuition Mental simulation Metaphor Storytelling
9. Fireground commanders make decisions in natural settings And hence, employ naturalistic decision-making as their predominant, individual modus operandi
10. The FiregroundProblem? 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
11. The Naturalistic Decision Making in the Environment Time pressure – Discretionary Time or Non-discretionary Time High Stakes – Lives Depend on Decisions Need for experienced decision-makers Inadequate information – Dispatch, Size-Up Ill-defined goals Poorly defined procedures – SOP/SOG Dynamic, contextual learning Teamwork – Only as strong as the weakest link. Is the weakest link in Command?
12. 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 and implement plans geared toward that course of action.
13. 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
14. 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
15. The Purchase of a Fire Truck Specs outline or describe the Fire Apparatus that is desired by the Fire Department. It specifies Eng Size, Transmission Size, Alternator Size, Tank Size, Pump Size, Compartment Size, Interior Design, etc.. Bids are turned in from different Companies. These bids include cost, options offered by different companies, availability of company to meet specs, etc These bids are reviewed by a departmental committee The bids are rated in terms of departmental needs The department chooses a bid and begins process for purchase. Classic Decision Making Model
16. 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.
17. Hit the Brakes Don’t be afraid to hit the brakes and slow down to increase the amount of time to make a sound/safe decision. Slowing down and making a good decision is always better than a hasty bad decision. Remember lives depend on your decisions. Both civilian and firefighters There are no do overs, take backs, or crying in firefighting Stop any and all actions that appear unsafe, have potentially dangerous consequences, look wrong, feel wrong, fall outside SOP/SOG, or do not fit into your plan of action
18. ….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!!
19. 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. Plan B & C are always necessary and some form or part of each will be implemented at some point. Hose breaks, people get tired, lights go out, tools get broke, pumps fail, medic units get delayed, trucks get lost, hydrants are dry, etc, etc, etc…..
20. Making a decision error when the correct situation is comprehended vs. making a decision error when the situation is incorrectly comprehended SITUATIONAL AWARENESS
21. 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) Listen to you gut, it almost never lies. When you are hungry, does your hand tell you? or your gut? That queasy feeling is there to let you know your getting sick about something.
22. 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.
23. 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)
24. Don’t let mental simulations skew the facts or ignore the situation. Remember situational awareness
25. 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
26. 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
27. 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
28. 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
29. 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!!!
30. 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.
31. What are our assets? Our minds and our memories Our bodies Limited diagnostic instrumentation Limited time Our collective minds

32. Use your team

    Learn to make decisions without technology
33. 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?
34. 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
35. How many times have you seen: Competent, well-meaning officers Knowledgeable and caring Able to instantly trouble-shoot problems FAIL during complex events?? FAIL during simple events?
36. 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
37. Our Acceptance of Adverse Effects 112 firefighters died last year across the nation While this number often fluctuates, it still remains around 100 each and every year. This statistic is a by product of the acceptance of the hazards associated with the profession and disregard for safety measures put in place to protect us. If commercial air travel had even a 0.1% major accident rate, it would result in 2 airliner crashes every three days….
38. 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
39. 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
40. Examples of Team Success Multi-alarm fires Mass-casualty Events Hazardous Materials Incidents Complex scene management Natural Disasters Man-made disasters
41. 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

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

    Interpersonal Communication
43. 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
44. 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
45. 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
46. 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...
47. 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
48. Making a decision error when the correct situation is comprehended vs. making a decision error when the situation is incorrectly comprehended SITUATIONAL AWARENESS
49. 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
50. 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
51. McBroom Hard man in cockpit to deal with Failure #4 Failure #5 Failure #6 Similarities in air ambulance crashes also
52. 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
53. 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...
54. 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
55. 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
56. 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!
57. 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
58. 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)
59. 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
60. The Cornerstones of CRM as taught by the FAA Situational Awareness Information gathering Frankly stated opinions Dispute resolution Decision Making Constructive criticism
61. 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
62. 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
63. 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.
64. 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.
65. 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.
66. 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.
67. 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...
68. 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
69. 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
70. 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
71. 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.
72. 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.
73. 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.