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Errors in Aviation Decision Making: Bad Decisions or Bad Luck?Despite efforts to design systems and procedures to support 'correct' and safe operations in aviation, errors in human judgment still occur and contribute to accidents. In this paper we examine how an NDM (naturalistic decision making) approach might help us to understand the role of decision processes in negative outcomes. Our strategy was to examine a collection of identified decision errors through the lens of an aviation decision process model and to search for common patterns. The second, and more difficult, task was to determine what might account for those patterns. The corpus we analyzed consisted of tactical decision errors identified by the NTSB (National Transportation Safety Board) from a set of accidents in which crew behavior contributed to the accident. A common pattern emerged: about three quarters of the errors represented plan-continuation errors, that is, a decision to continue with the original plan despite cues that suggested changing the course of action. Features in the context that might contribute to these errors were identified: (a) ambiguous dynamic conditions and (b) organizational and socially-induced goal conflicts. We hypothesize that 'errors' are mediated by underestimation of risk and failure to analyze the potential consequences of continuing with the initial plan. Stressors may further contribute to these effects. Suggestions for improving performance in these error-inducing contexts are discussed.
Document ID
20020063485
Document Type
Preprint (Draft being sent to journal)
Authors
Orasanu, Judith (NASA Ames Research Center Moffett Field, CA United States)
Martin, Lynne (NASA Ames Research Center Moffett Field, CA United States)
Davison, Jeannie (NASA Ames Research Center Moffett Field, CA United States)
Null, Cynthia H.
Date Acquired
September 7, 2013
Publication Date
January 1, 1998
Subject Category
Air Transportation and Safety
Meeting Information
Fourth Conference on Naturalistic Decision Making(Warrenton, VA)
Funding Number(s)
CONTRACT_GRANT: NASA Order H-6687-S
PROJECT: RTOP 548-31-32
Distribution Limits
Public
Copyright
Work of the US Gov. Public Use Permitted.

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