Safety Spotlight: Think you’re immune?
Decision-making pitfalls affect everyone
Recently, two events made me realize this question needed more serious and deliberate contemplation. I read an excerpt from the 2008 book Think Again: Why Good Leaders Make Bad Decisions and How to Keep It From Happening to You. The article includes an interesting explanation about the brain’s decision-making process. Shortly after reading the article, a horrific accident came across my news feed. A pilot in a twin with four family members attempted a takeoff in near-zero-visibility conditions in fog. The takeoff ended tragically with the aircraft crashing just after liftoff and prior to the airport boundary. All on board perished. The final investigation won’t be complete for some time, but regardless of what the NTSB determines, the decision to depart heavy weight, with four family members in near-zero-visibility conditions for a leisurely out-and-back flight is troubling. The flight was not “necessary.” The fog was expected to burn off later that morning. What leads an experienced pilot to make a decision to fly under those circumstances, so fraught with risk?
The Harvard Business Review article may provide some insight. The authors explain that our brains aren’t naturally inclined to lay out all the options, consider the pros and cons, assess the consequences, and then make a decision. We’re wired to make a quick assessment based on previous patterns in our memory, tag it with an emotion, make a decision, and move on.
Some elements associated with this decision process are problematic in the dynamic and fluid aviation environment. First, patterns can be associated with previous encounters, despite small differences that significantly change the situation. Think about a takeoff in near-zero-visibility conditions and all the variables that would have to be consistent for this pattern to be truly repetitive. Has the pilot executed this kind of takeoff before? How proficient was he when he did it? How rested was he? What were field conditions? Was the airplane this heavy? Were there distractions of family and friends on board? A change in any of these parameters affects the dynamics of the situation. So while it might appear to be similar to our brains, it could in fact be a significantly different situation, requiring a modified, or perhaps an entirely contrary decision.
The second problem with our natural decision-making process in an aviation environment is emotional tagging. Our emotional attachment is highly influenced by our own self-interest. This is in part why “get-home-itis” is a phenomenon in aviation. We can talk ourselves into a decision because the outcome serves our self-interest. We also tend to favor advice from people we like, and we get attached to things such as our “home field.”
Another challenge is our natural inclination to stick with a decision once it’s made, and look for corroborating evidence the decision is a good one. In the face of significant evidence that we are on a bad path, or that the situation has changed unfavorably, we tend to find the morsel of information that confirms our original decision and heavily overweighs that evidence to stay the course. I’m thinking of the accidents I’ve reviewed where there was plenty of evidence that should have encouraged the pilot to cancel a flight or divert to an alternate, yet he continued to tragic results.
Given the limitations of our natural decision-making process in the aviation environment, we must be especially aware of any challenging situations in which we find ourselves influenced by the fact that “we’ve done this before,” or we have an emotional bond to a person or place in the situation; that we have strong self-interest in arriving somewhere; or that we seem to keep discounting adverse information. Our mitigation strategies can include checking our memories to be sure we have encountered this exact situation with all of the variables; discussing the situation with a knowledgeable and trusted colleague; allowing ourselves to consider the full range of options rather than just variations on the “go decision”; and fully assessing each new piece of information in context of the entire decision.
Decision making lies at the heart of aviation excellence. Go fly—but before you do, double-check your decision process and look for warning signs.
