Avit final

Administrative oversight

- policies, licenses

Response to time pressure

1. Accelerating activity- • Faster pace of activity, eliminating rests, pauses, or interruptions 2. Filtering information- • Prioritize information received, using only what is needed • Negative information receives a higher priority 3. Problem solving strategies change- • Strategies don't use all of the information available • Strategies look at the single most critical aspect of the situation and react to it. • Strategies make use of less information These natural responses do not increase the quality of the decision, just the speed of the process

• Interference with motor skill development:

1. Distraction in the early learning phases 2. Inadequate time to develop basic skills

Biases (restated)

1. First Impression 2. Hindsight • Confirmation Bias 3. Seeking information 4. Spinning information 5. Expectation Bias • Believe only what you think is right • STM Limitations 6. Seek more info than we can retain 7. Consider few options 8. Consider only critical aspects • Evaluation Challenges 9. Sources of information 10. Option quality

Improving vigilance

1. Use the appropriate type of attention. • Selective, Focused, Divided, and Sustained... which is best for the situation at hand? • Distraction Management 2. Knowledge and recall of systems / procedures • What problems/risks are you looking for...? 3. Using perceptual skills and understand their limitations • Visual illusions and spatial disorientation....

preconditions

3 Categories • Environmental • Physical - weather, heat, lighting, etc... • Technological - automation design and layout, interface • Condition of Operators • IMSAFE • Physical or Mental limitations - unable to cope with situation (not enough time to react) • Personnel Factors • CRM issues • Attitudes and Personalities

Visual perception challenge

80% of our perception is visual information • Relative motion • Objects that move in our visual field are easier to detect • Vibration and acceleration: Your ability to visually focus and follow objects (tracking) are affected.

Visual perception concepts

Central and peripheral vision roles are different. • Central vision is where your acuity and color vision is best. • Used for high resolution and focus.

Aviation error management strats

Checklist use • Pause and visual verification • Standardized terminology • Standardized procedures • Assertiveness training

Examples of decisional errors

Decisions that are incorrect • By knowingly: • taking off with a 20 knot tailwind • flying under bridges • continuing flight into IFR conditions with inadequate training or equipment • Any intentional act that increases safety risks is considered a decisional error.

Deadwood to jets

Delivering passengers and mail 100 years ago to flying jets. • Small on the outset, buy stagecoaches. • Tough hazardous conditions (bandits, deserts, bad roads. • Fault is localized - not organizational

Recognition-Primed Decisions (RPD)

Depend upon prior experiences / knowledge • Tend to create viable options quickly • 90% of decisions of experienced professionals

Multiple resource theory

Explain multitasking and performance degradation

What factors influence decisions

General Aviation: Poor judgment is seen in 52% Fatal Accidents

Distraction

Redirects attention and perception resources elsewhere

Perception

The ability to gather and interpret sensory information

Perceptual errors

These errors are incorrect responses that result from faulty perception interpretation. • Typically occur when sensory information is degraded or 'unusual'. • Visual illusions, spatial disorientation • Contrast, depth cues, light angles... remember?

Violation

Willful disregard for rules and regulations that govern the safety of flight

Judgment is:

a cognitive process • Several phases (or steps) are involved • is more than the final act of option selection. • Better stated: Judgment is the sum of awareness management, decision-making, and risk assessment.

Focused attention guidelines

• Avoid confusion with distractions • Make competing information appear different. • Separate / decrease distracting influences. • Does this sound like studying? How can you optimize studying? • Avoid Loss of Situation Awareness! • Crew coordination, attention discipline • What accidents have been caused by this factor?

Decision

• Choosing your option • What skills are needed to reach a decision? • The ability to complete the process.... • Leadership skills • How do we develop skills to make decisions?

Our own errors

• Co-existing circumstances • Time pressure • Unclear information • Lack of recent experience • Embarrassment • Liability / Blame / Consequences • Damage to Reputation • Pride, Not wanting to be corrected

Problem diagnosis skills

• Correctly identifying the problem • Supporting skills: • perceptual skills in gathering information • memory recall of affected systems or procedures • problem-solving/critical thinking skills • abstract reasoning skills to test problem theories

Perceptual (forms of judgement)

• Decisions are based on familiar perceptions • Experience, learning in similar settings, helps speed judgments • Skills that are well learned • Tend to be faster

Improving selective attention

• Decrease the number of sources you have to monitor. (This would decrease __ __ ) • Crew coordination can assist • Prioritize the sources you monitor. • Develop strategies to maintain priorities • Place gauges close together. (Standard T) • Train operators in correct and effective scan techniques.

Summary

• Developing learning skills that match brain physiology increases learning efficiency. • Memory types have incredible capabilities, but limitations have a significant impact on human performance.

First impression rule

• Early information is considered more important or accurate. • Early impressions can be given preference when information sources conflict...

Background problems

• Emotional aspects that influence decisions • Can affect any aspect of the rational choice decision model • Examples? Do attitudes often influence bad decisions? • Why is this a major concern to airlines? • Can be variable and very difficult to detect prior to impairment

Skill based errors

• Failure during actions or behaviors that are established. • Attention and memory failures are common • Examples • Distractions, forgetting procedural steps, poor technique

routine violation

• Habitual in nature and tolerated by the supervisory level • Usually affected by the culture of the group. • Can be somewhat predictable

Perceptual errors examples

• Hard landings are due to what? • Improper perceptions (height above runway) • Wider than normal runways leading to illusions • Spatial disorientation accidents • Misreading instruments

Background

• Hazardous attitudes • Peer pressure • Get-home-itis • Financial pressure • Discontent • Sense of commitment • Illness • Fatigue • Medication • Dependence • Intimidation • Lack of discipline • Embarrassment • Desire to impress

Summary

• Human bias in information gathering and decisionmaking is well known and common. • Awareness of these biases will aid in avoiding poor decisions. • Humans will develop strategies to most comfortably address problems, and these strategies may be inadequate. • Time pressure is most commonly our own doing, and has a significant impact on performance. • Attention Anomalies are a common accident contributor. • Awareness and discipline are key to the solution.

Short term memory limitations

• Humans seek more information than they can absorb in a given time. • We usually consider only three or four options at a time, rather than a larger number. • We only consider a few critical aspects of the problem.

Micro matching

• Identifying decisions or actions and comparing them to new or created standards • Used a lot to prosecute negligence • If the data was available why didn't they pick it out.

Can good judgment be learned?

• Information can be learned and tested, but can we learn judgment? How? • Develop your perceptual skills • Learn what information is necessary to evaluate the situation • Practice by making decisions • Carefully assess the results of your decisions.

short term pt 2

• Information is encoded several ways • Visual - visualize the information • Phonetic - auditory or sound processing • Semantic - information has meaning • All coding systems may be used. • How does this create challenges? • Would you more easily confuse C with B or O? • What are the implications in aviation?

Cognitive (forms of judgement)

• Information uncertain • Multiple factors and alternatives to consider • Risk assessment is more difficult / less certain • Needs a high level of attention and concentration • More time is needed

Exceptional violation

• Isolated departure from guidance • Engaging in prohibited maneuvers not sanctioned by the authority.

Sustained attention guidelines

• Keep operators alert and motivated: • Work-Rest cycles, changing tasks, and environmental control are important • Make signals easier to detect • Louder, brighter

short term

• Limited capacity, short duration. • Attention is required. • Capacity is 5 to 9 items • Information will be more difficult to retrieve over time, especially with more items to remember. • Meaningful information is easier to remember. • Capacity is improved by "chunking" information.

Altered appearances compared to ground ops

• Loss of light scatter (dust and humidity) • Haze is a distant visual cue • Light sources from below • Light angles can hide shadow cues • Loss of Depth, Texture, and Size cues • Indistinct features are difficult to assess

Divided attention guidelines

• Minimize workload. • Reduce difficulty levels of the tasks. • Well-learned manual tasks are better tolerated in these settings. • Avoid assigning tasks that share resources. • Airlines require callouts on approach...why? • Task priority is important...

Selective attention

• Monitoring separate sources of information (sequentially) to perform a task. Example... • Load stress is the number of sources. • Speed stress is the rate the information is changing. • Of the two, load stress is a greater factor in performance. • Under time pressure, we tend to monitor fewer sources. • Early IFR simulator lessons...what is a common error?

Sustained attention

• Monitoring your surroundings for abnormalities • Sustained attention is difficult to maintain • Within 20-30 minutes: Reduced speed and accuracy of responses to abnormalities

Rational choice decisions

• More commonly used when • Options need to be created, instead of recalled • Situations are unfamiliar or difficult to classify • Only seen in approximately 10% of decisions in aviation professionals • More complete evaluation of the issues • Not necessarily a better decision

Learning motor skillls

• Motor skill development requires reinforcement over time. • Repeated stimulation prompts nerve pathway changes, developing an engram. • Do your skills degrade without practice?

Negative transfer (skill based error)

• Negative transfer: • Doing the old procedure instead of the current one • Driving: Going from a manual to an automatic transmission... • Retracting landing gear while intending to retract flaps

Nerve stimulation results in physical and/or chemical changes.

• Neurons change to retain information • Well-developed nerve pathways (engrams) are created by repeated use. • Have better storage and retrieval capability • Can be created by emotion or timely repetition

Points to remember

• Orientation of an object is a critical aspect of visual perception. • Context influences our perceptions - librarian or farmer • Extraneous cues are powerful in creating visual illusions (Fog, Haze, Shadows, etc...) • Assumptions are often made subconsciously, and although helpful at times, may be false (System 1 vs System 2)

Summary

• Our ability to perceive is a critical skill. • Remember, our perception has limitations. • Spatial disorientation is a killer. • Most of our perception is subconscious. • Perception problems most often result from environmental conditions or the way we subconsciously modify our perceptions. • When things don't make sense: Consider that perception may be the source of problem.

Stimulated nerves record information

• Our ability to recall is based on memory type

Bias is a preference in the way we approach decisions, based on our prior experience.

• Our experience creates subconscious assumptions, which filter information and impact our decisions. • As a result, we make decisions that seem reasonable, but are later viewed as irrational decisions.

Concepts of perception

• Perception can be influenced by your thoughts or paradigms. • Experience, Confidence, Motivation, etc. • Your 'senses' also have limitations to detecting changes. Consider movement...

Divided attention

• Performing two or more tasks at the same time. • Ex. Maneuvering while talking on the radio. • Resource-sharing is the main issue affecting performance. • Increasing workload is also an issue. • Example: What happens to the conversation in the car when the weather gets bad?

Shopping bag (taken out of context)

• Piecing information without regard to relation or sequence

How we acquire poor judgment:

• Poor information gathering • Lack of risk assessment experience • Improper training • Vicarious learning • Learning inappropriately • Impaired troubleshooting • Hazardous attitudes

Vigilance

• Prior to problems occurring, we must 1. be alert and 2. have knowledge of operational risks. • Perceptual skills to detect problems • Not only for general detection, but anticipation of problems that could occur • Takeoff actions are... • Fuel selection procedures are... • You detect icing conditions by...

Summary

• Rational Choice differs from RPD primarily in the way options are generated and risks are evaluated. • Certain components described in Rational Choice Decisions are seen in all decision processes. • Vigilance, problem discovery, problem diagnosis, decision, action, and background

Alternative generation skills

• Recalling or creating options • Skills used: • Critical Thinking Skills: Comprehension, Synthesis, Application • Are there standard procedures for this? • If not, what is available? • How creative are you? Do the options fit the situation? • How well do you know the systems involved and those available? • Knowledge limitations restrict options....

Problem discovery

• Recognition of a change in status, with or without warning • Is the change you notice an abnormality or not? It can be a challenge... • Supporting skills: • Your experience • Procedures and systems knowledge • Recently reviewed information

Long term

• Retains information and skills for long periods • Engrams are formed in long term memory • Transfer is by semantic coding • Attention to learning environments is key • Organized and learned correctly the first time • Visual images, Mnemonics (BCGUMP) help • Repeated stimulation using retrieval mechanisms

Attention types

• Selective Attention • Focused Attention • Divided Attention • Sustained Attention (Vigilance)

what are resources

• Stages: What level of brain activity is needed? • Input sources: eyes or ears (perceptual sources)? • Processing codes: What type of task is performed? • Response type: What type of actions are done?

Sensory memory type

• Temporary storage in each sensory channel (vision, hearing, etc.) • Automatic, used to process information • Does not require attention • Auditory - information held for several seconds • Visual - held for approximately 1 second

Memory

• The ability of the brain to organize, store, and retrieve information. • Storage capacity is vast and impressive, but retrieval of information is imperfect. • Memory and retrieval mechanisms are complex, and are studied by models. • Models don't explain all aspects of memory.

Risk analysis

• The aspect asks: 'What is the likelihood and impact of failure of each option?' • Skills needed: • Experience and understanding of the options • True understanding of the ramifications of each option • Critical thinking skills: Analysis, evaluation

Discussion of learning

• The goal is to: • Create engrams for accurate and efficient recall • Organize your materials and study habits • Develop semantic coding through understanding the material • Study by developing and testing your retrieval skills

Decision making models

• The process can vary according to: • the situation at hand, • experience of the individual, and • time available.

Action

• The process of coordinating actions to carry out your choice. • Skills needed: • motor, communication, and interpersonal skills • Efficient actions require an understanding of: • Competing resources (noise, disagreement) • Leadership, Communication, Crew Coordination • Man-machine interfaces (more later)

Confirmation bias

• The tendency to favor information that conform to your expectations or beliefs (We like to be right) • Spin (Interpret information to fit) • Seek (Only look for information to fit)

Time pressure

• Time pressure is more often a result of poor planning/inefficiency rather than an emergency • Decreased: quality, accuracy, and confidence. • Simpler strategies are used • Complete problem-solving process is not possible • Option generation and risk analysis is limited

Error management strats

• Two major approaches to error management are used: 1. Minimize frequency of errors 2. Reduce consequences of errors already committed. Threat -Error - Undesired State (manage threats, reduce the frequency and consequence of error).

Someone else's errors

• Unexpected • Below standards • Not current...trust? • Not paying attention • Should have known better • Precedent behavior • Uncertain how to correct • Varying consequence of an error

Hindsight bias

• Viewing information when you know the outcome alters your viewpoint / analysis. • Confidence that says • "I would never do that" • "I would have known that" You see an event that has already happened as more predictable after it has happened.

Judgment process model

• Vigilance • Problem Discovery • Problem Diagnosis • Alternative Generation • Risk Analysis • Background • Decision • Action

Evaluation challenges

• We consider all information to be equally reliable, when it is not. • Evaluate your sources for reliability... • We appear to have less confidence in evaluating and choosing alternatives. • The 'benefit of the doubt'

Memory is

• a result of nerve stimulation and • will fade without efforts to transfer to long term memory. • This process requires attention.

Errors occur

• in many ways, • in varying conditions and • have variable results. • Error can occur as a result of action, inaction, or with the operator totally unaware of the problem. • Error can be the result of an incorrect action or be due to failing to detect or report a previously committed error.

Peripheral vision is used for

• orientation, • assessment of your speed (field flow), and • detection of motion in your surroundings.

• When performing two tasks, interference increases as:

• task demands increase, or • greater sharing of resources.

Cherry picking

Only choosing points to confirm your ideas

Error classification

Operators can intend to do incorrect actions, without intending to have an accident. • Classifying error helps us to... 1. Correct the process of the error committed 2. Prevent the same error from being committed in the future

The purpose of attention is to manage one's resources.

Our ability to direct resources to an area of interest or need.

Expectancy

our perception can be altered by our expectation of what we are about to perceive (we select based on what we think the outcome should be)

Errors

When a planned series of actions fails to achieve the desired outcome and when this failure cannot be attributed to the intervention of some chance occurrence." Senders and Moray

Habituation

s ignoring a predictable and recurrent input (decreased response after repeated exposures)

Negative transfer

the process of using procedures from a previous setting inappropriately in a current setting.

What is judgment?

• A decision, opinion or conclusion after due consideration. American Heritage Dictionary • What is due consideration? • Do we have adequate time for due consideration in emergencies? • Do we ever make decisions faster than needed, and does it effect the quality of our decisions?

Error chain

• A series of errors, or chain, creating conditions favorable for an accident. • Each link is critical to the development of the chain. • Each link may be independent of each other, but together they create a hazardous situation. • One error increases the likelihood of the significance of other errors. • Correct even minor or seemingly insignificant errors.

Effective learning

• Actively engage in the class discussion • Take 'semantic' notes • Review immediately after class • Within 24 hours: Create questions that challenge your recall • Focus on weak areas • Don't just read notes repeatedly

focused attention

• Attention is directed to a single or few sources. • Distraction and loss of situation awareness are key problems.

Threat

Any environment, attitude, condition, or other influence on the quality of your decisions or actions

Attention type

Attention type can be changed quickly and subconsciously

Decision errors

Intentional behavior that is performed as expected, yet is inadequate or inappropriate for the situation. • Inadequate knowledge • Poor choices

Error

any action in which the desired process or outcome is not achieved

Short comings of theory

does not explain everything continual research being done

operator actions

errors, persistence, violations

preconditions

fatique, information overload

Supervisory controls

identify and correct problems - cops