Decision-making for Dummies

We’ve all done it at one point or another. We were moving happily and uneventfully along in some process or another and then we accidentally skip a step. We may not realize it right away, but eventually the omission comes to light. With a little luck, the mistake doesn’t cost us much in the way of time or money, but in many cases, the repercussions can be disastrous.

Gimli Glider

In 1983 a new Air Canada Boeing 767 full of passengers was making its way from Montreal to Edmonton. Cruising along at 41,000 feet the unthinkable happened: low pressure alarms relating to the fuel tanks signaled a problem to the pilots and then the plane’s engines stopped, one after the other. Watch this reenactment for the details of the plane that became known as the “Gimli Glider”:

It is estimated that 75% of all aviation accidents are human factor related. In the case of the Gimli Glider, the computerized Fuel Quantity Information Processor was not working properly so the pilots and ground crew resorted to calculating the fuel needs by hand.

Unfortunately, both pilots and ground crew failed to recognize that they were using the wrong factor in a fuel equation used to determine how much fuel would be needed for the two legs of the flight they were making. The plane was the first to use the newly instituted metric system in its computer systems and everyone was used to the old imperial system. Nobody realized the error.

As with Captain Sullenberger and the fated U.S. Airways Flight 1549, Captain Pearson’s glider experience and the cool and collected reaction of the pilots saved the lives of a plane full of passengers [note to self: get glider training].

The FAA does a lot of work to study accident statistics and implement training programs for pilots to make flying safer. I was rereading some of my training books recently and came across a chapter on something the FAA calls “aeronautical decision making” (ADM). According to the FAA, ADM “is a systematic approach to the mental processes used by airplane pilots to consistently determine the best course of action in response to a given set of circumstances.”

The FAA designed a model, called “DECIDE,” to provide pilots with a framework for effective decision making. This model is useful in any field of activity. Check it out!

DECIDE MODEL

Detect the fact that a change has occurred.

Estimate the need to counter or react to the change.

Choose a desirable outcome for the success of the flight.

Identify actions which could successfully control the change.

Do the necessary action to adapt to the change.

Evaluate the effect of the action.

Note that there are several steps before choosing a course of action. Impulsive decision making is often dangerous. Note as well that the process isn’t over when the adjustment is made. It is always worth evaluating actions you’ve taken in response to change. Though you may feel like a worker bee at times, you needn’t resort to acting like a drone.

Most failures are preceded by a chain of poor judgments. Sometimes referred to as the “error chain,” it is not uncommon to see one mistake leading to another, rendering the final outcome far from ideal. The good news is that as with any chain, breaking one link in the chain is normally all that is necessary to change the outcome of a sequence of events.

Making sound decisions is the key to preventing accidents. If you are accident-prone or if you tend to miss steps here and there, take note of the DECIDE model. It may save your life some day!

9 thoughts on “Decision-making for Dummies

  1. Mitchell Webb

    Amazing that the pilot flew and landed a 130 ton airliner just like a half-ton sailplane. A tongue and cheek moral to this story might be to “think metric”… but I think it translates well that we need to expand our ability to problem solve and think ‘out of the box’ so that we can detect our own errors or the errors of others and have the necessary preparation back of us and ability to think quickly if and when we are confronted with difficulty.

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  2. Henry Frey

    One part of the story that jumps out at me was the knowledge, skill and calm demonstrated by the pilots when encountering a situation that was unprecedented in their experience and training. Their preparation and resolve saved lives. Technically the pilots were part of the error chain. Thank God for their expertise handling of the emergency, but it speaks to me loudly that the blame is not simple in such cases and the best way to avoid failure is to make sure I am doing my job actively and thoroughly.

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  3. Colin

    Wow this is a great post. I can see so many uses for this type of reasoning. I also really like that it only takes the destruction of one link in the error chain to divert a disaster from happening. I guess a main point here is “don’t let the little mistakes turn into a big mistake”. The little mistakes could be as innocuous or common as fatigue. If you can recognize these danger areas beforehand or at least factor them into your planning (I’m tired so I better check this once more), you could prevent something very bad from happening!

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  4. Mark

    The Gimli Glider story stands as a testimony to the importance of thoroughness and preparation in the first place, but also calm in the process of DECIDE to handle the obvious deviation or emergency. Amazing story!

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  5. Ed Barnes, Sr

    I highly recommend a book called “The Survivor’s Club” – there is a chapter dedicated to airline disasters which analyzes common aspects of the error chain and reveals some interesting human factors which anyone could usefully be aware in their daily work and interactions.

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  6. J. Cannen

    Great example and outline applicable to anyone. One of the most challenging aspects of leadership at any level, captain, maintenance or otherwise, pertains not just to getting the job “done”, but also ensuring that the most precious resources–personnel–are performing each and every function safely and by the book, no shortcuts, no misunderstanding of protocol. Ultimately personal responsibility at every level is what will break the error chain and prevent failure and disaster. Critical thinking, good communication habits and a solid work ethic benefits us across the board.

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  7. Brad

    What a great tool ~ already used DECIDE this morning and on a much better course ~ can’t wait to find more applications ~ thanks for the idea!

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  8. Isabelle Kearney

    Wow, what a stark example of what sounds like a simple mistake leading to huge consequences. The “decide” model sounds like a great tool for helping you to keep your head in any situation. The important thing being, that there is a chain of events and that any part of the chain can be impacted by our decisions, either good or bad.

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  9. Marianne

    That video had me on the edge of my seat! All your points are excellent, especially the note to self to get glider training – anywhere we can see to shore up is a good prevention.

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