Naturalistic Decision Making

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Decisions, decisions.
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Naturalistic Decision Making
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How We Make Individual DecisionsWhy We Fail as
Teams

• How do individuals make decisions?
• Do we look at possible alternatives, weigh
  costbenefit 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?

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It Depends..

• It is dictated by the situation and environment.

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The Matrix
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What do we want to accomplish?

• Whos Cooking?
• Price
• Previous History
• Clean-up
• Taste

• Fast Attack
• Rescue
• Exposures
• Water supply
• Fire conditions

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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

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Top Gun
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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.
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Sources of Power

• Conventional
• Deductive, logical thinking
• Analysis of probabilities
• Statistical methods

• In Natural Settings
• Intuition
• Mental simulation
• Metaphor
• Storytelling

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Fireground commanders make decisions in natural
settings
And hence, employ naturalistic decision-making
as their predominant, individual
modus operandi
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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

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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

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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

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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

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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

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We dont 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.
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Hit the Brakes
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.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!!

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CONSTRUCT PLAN B C

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

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Making a decision error when the correct
situation is comprehended vs. making a decision
error when the situation is incorrectly
comprehended
SITUATIONAL AWARENESS
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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)

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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.

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• Even though we dont 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)

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• Dont let mental simulations skew the facts or
  ignore the situation.
• Remember situational awareness

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A Whale of a Problem
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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

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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

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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

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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

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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!!!

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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.

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What are our assets?

• Our minds and our memories
• Our bodies
• Limited diagnostic instrumentation
• Limited time
• Our collective minds

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Use your team

• Learn to make decisions without technology

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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?

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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

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THE BORG
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How many times have you seen

• Competent, well-meaning officers
• Knowledgeable and caring
• Able to instantly trouble-shoot problems
• FAIL during complex events??

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Its 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

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Our Acceptance of Adverse Effects

• of Arlington Firefighters are injured every
  year.
• 112 firefighters died last year across the
  nation
• But were 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.

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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

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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

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Examples of Team Success

• Multi-alarm fires
• Mass-casualty Events
• Hazardous Materials Incidents
• Complex scene management
• Natural Disasters
• Man-made disasters

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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

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

• Interpersonal Communication

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The United Air Crash Lesson

• Cockpit voice recorder excerptscontributing
  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

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The Cast

• FA (Flight Attendant)
• McBroom- Pilot and One of Uniteds most senior,
  experienced captains
• Frostie- (Mendenhall)Flight engineer
• AC- Air traffic controller
• Beebe-First Officer

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544 PM

• FA- Ill be honest with you, Ive never had one
  of these before, my first you know
• McBroom- All right, what well do is have
  Frostie, oh about a couple of minutes before
  touchdown signal for brace position
• Failure-didnt acknowledge the attendants anxiety

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550 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...

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550 PM

• Beebe-OK, left zero-five-zero
• AC- United 173 heavy, clear of first traffic, now
  theres one at
• Failure 1
• Failure 2
• Failure 3

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Making a decision error when the correct
situation is comprehended vs. making a decision
error when the situation is incorrectly
comprehended
SITUATIONAL AWARENESS
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601 PM

• AC- Did you figure anything out yet about how
  much longer?
• Beebe- .Itll be our intention to land in about
  five minutes on two-eight left, we would like all
  the equipment standing by
• Time60106PM

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603PM

• McBroom- Very well, theyve about finished in the
  cabinId 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

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McBroom

• Hard man in cockpit to deal with
• Failure 4
• Failure 5
• Failure 6
• Similarities in air ambulance crashes also

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604PM

• McBroom- OK, were 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, Ill make the five minute announcement,
  Ill go, Im sitting down now
• Beebe- Better get the crossfeeds open!
• Mendenhall- OK
• FA-All righty
• Failure 7

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604PM

• Beebe- Were losing an engine, buddy
• McBroom- Why?
• Beebe- Were losing an engine
• McBroom- Why?
• Beebe- Fuel
• Beebe- Open the crossfeeds, man!
• McBroom-Open the crossfeeds there or something
• Mendenhall- Showing fumes, guys...

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604PM

• McBroom- Showing a thousand or better
• Beebe- I dont think its in there
• Mendenhall- Showing three thousand, isnt it?
• Failure 8
• Failure 9
• Failure 10

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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

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607PM

• Beebe- Its flamed out
• McBroom(radio) United 173 heavy would like a
  clearance for an approach into two-eight left,
  NOW
• Mendenhall- Were going to lose number three in a
  minute, too.
• McBroom- Very well.
• Mendenhall- Its showing zero.
• McBroom- You got a thousand, you got two!

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612PM

• Beebe- Lets take the shortest route to the
  airport.
• McBroom-(to AC) Whats our distance now?
• AC- Twelve flying miles.
• (?)- Well, (deleted)
• McBroom- About three minutes, Four
• Mendenhall- Weve lost two more engines, guys
• Failure 11
• Failure 12

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613PM (plus 23 minutes)

• AC- Have a good one!
• McBroom- Theyre all going
• McBroom- We cant make Troutdale
• Beebe- We cant make anything
• McBroom- OK, declare a Mayday
• Beebe- Portland tower, United 173 heavy. Mayday,
  mayday, werethe engines are flamming out, were
  going down, were not going to make the airport.
• Tower- United one-seven(sounds of impact)

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Uniteds 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

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The Cornerstones of CRM as taught by the FAA

• Situational Awareness
• Information gathering
• Frankly stated opinions
• Dispute resolution
• Decision Making
• Constructive criticism

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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 youor others
• Ask for help when you need it

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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

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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.

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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.

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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.
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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.

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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...

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Lets understand ourselves...

• Many of us like to control situations and people
• We are externally driven
• We like to see results quickly
• We are individualists

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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

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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

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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.

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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.

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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.