1. Strategic Team Decision Making Florida Reliability Coordinating
Presented to the:
Florida
Reliability
Coordinating
Council

2. The Challenge of Decision Making
Multiple Players
Vague Goals
Dynamic
Settings
High Task Loading
Time Stress
Uncertainty
Organizational
Factors
High Stakes

3. Human Error

4. SKILL-BASED PERFORMANCE LEVEL
The performance of highly routine activities in familiar circumstances (i.e., performing a routine task). Performance is governed by stored patterns of preprogrammed (trained or practiced) instructions.

5. RULE-BASED PERFORMANCE LEVEL
Handling familiar problems in which solutions are governed by stored rules of the type if (state) then (diagnosis) or if (state) then (course of action). Performance is governed by stored rules that are accumulated through experience and learning.

6. KNOWLEDGE-BASED PERFORMANCE LEVEL
Comes into play in unique situations for which actions must be planned on-line, using conscious analytical processes and stored knowledge. Performance relies on our ability to analyze with no preprogrammed instructions or rules.

7. Human Error – Failure of intentions to achieve intended results
Omit Key Action
Repeat Action
Jump Ahead
Forget Intention
Wrong Object
Percep. Confusion
Slips or
Lapses
Skill-Based Error
UNINTENDED
ACTION
Mistakes: actions succeed, plan inadequate
Violations: deviation from procedures or rules
Misclassify Event
Locking In
Ignoring Signs
Info Overload
Rule Strength
YOUR INTENTIONS
Rule-Based Error
Knowledge-Based
Error
Incomplete Information
Incorrect Information
Wrong Attention
Availability Bias
Over Confidence
INTENDED
ACTION

8. Recognition-Primed Decision Making

9. Recognition-Primed Decision Model
Situation
Cues
generates
to affect the
Mental Models
using your
Mental Simulation
which you assess by
Patterns
that let you recognize
Action Scripts
that activate
Adapted from Recognition-Primed Decisions Model in Gary Klein’s, Sources of Power, The MIT Press, 1998

10. Why We Struggle With Decisions
A lack of experience with the situation
Not recognizing anomalies in a situation
Not mentally simulating a course of action
Not prioritizing cues to avoid high workload
Not developing expectancies
Not identifying plausible goals
Not anticipating how a course of action could run into difficulties
Acute stressors
Time pressure
Uncertainty
High workload
Tendency to explain away early signs of problems

11. Ways in Which Errors May Occur
Situation Assessment Errors
Develop incorrect interpretation of the situation
Cues misinterpreted, misdiagnosed, or ignored
Risk levels misassessed; time available misjudged
Situation models not updated
Course of Action Errors
Appropriate response not retrieved from memory
Inappropriate rule applied to situation
Options not considered; consequences not evaluated
Relative strength of competing goals

12. Major Contributors to Decision Errors
Continuing with the original plan of action (in the face of cues that suggest changing the plan)
Ambiguity (cues may not be recognized)
Organizational factors (emphasis on productivity)
Social factors (real men don’t admit ignorance)
Underestimating risk (based on success in the past)
Consequences not anticipated (projecting future)
Lack of information (poor system design or poor communications)
Unconscious attempt to make available evidence fit a preconceived scenario
Lack of knowledge (lack of familiarity)

13. Ways to Avoid Common Errors
Situation Assessment Errors
Update your models (situation awareness)
Keep entire team updated (alignment)
Voice and resolve conflicts
Course of Action Errors
Fight recency bias
Do mental simulation
Seek other’s input

14. “It’s not what you don’t know that can hurt you, it’s what you do know that ain’t so!”

15. What Is Important? Your technical skills and knowledge
Your individual teamwork skills
How you work together as a team
How you make decisions as a team
How you think as a team

16. Collective Consciousness
THE TEAM MIND
Sub-Consciousness
Collective Consciousness
Adapted from Cognitive Processes of the Team Mind by M. Thordsen and G. Klein, Klein Associates Inc., IEEE Transactions, 1989

17. Increase the Level of Collective Consciousness
THE TEAM MIND
GOAL:
Increase the Level of Collective Consciousness
Adapted from Cognitive Processes of the Team Mind by M. Thordsen and G. Klein, Klein Associates Inc., IEEE Transactions, 1989

18. Team Out of Alignment Confusion Different Picture
Same Picture – Different Interpretation
Missing Cues
Misinterpreted Cues

19. Aligned Team
Situation
Main Effort
Course of Action

20. The Team Decision-Making Skills
Leader’s Intent
Conflict
Resolution
Information
Exchange
Questioning
Creating Understanding
Adaptability
• Managing
Stress
Situation
Awareness
Management

21. Situation Awareness Bubble
Accurate Perception of:
What Is
Happening SA
Why It’s
Happening
What might
Happen

22. Situation Awareness
Where is this Warning Light?
CAUTION
S.A. at Risk

23. Red Flags/Traps to Losing Situation Awareness
Crew preoccupation with minor problems.
Disparity between plan and actual situation.
Failure to resolve ambiguities.
A feeling of contentment or satisfaction (complacency).
Failure to communicate leader’s intent and plans.
Failure to set priorities.
Inadequate monitoring.
Inadequate leadership - no one standing back monitoring the state/progress of the event and crew.