The risk matrix

All of the above involve predictions about the likely future course of events, and as has often been quipped, predictions are difficult to make, especially about the future. This has some important consequences in terms of decision making in aviation and all similar high risk industries, based on two self evident truths. The first is that in managing any situation you find yourself in, your initial course of action is to ‘first do no harm’. In other words, don’t knowingly or unknowingly increase the operational risk dynamic by the decisions you make. The second is to constantly be working to appropriately maintain or manage your existing or future operational risk within clearly defined limits and goals, since every commercial operations manual will state somewhere ‘safety is our number one priority’.

Poor decisions in aviation frequently result from either applying the wrong rule to the correctly assessed or projected situation; from applying the correct rule to an incorrectly assessed or projected situation; or by applying the wrong rule to an incorrectly assessed or projected situation. Once again, remember that the situation is dynamic and constantly evolving, whether you recognise it or not.

Adapting the knowledge matrix that was introduced in an earlier article allows us to define any operational situation that a crewfinds itself in into one of four types: • The crew recognises that they know what is going on around them – ie they know that they know; • the crew recognises that they don’t fully understand what is going on around them – ie they know that they don’t know; • the crew does not recognise that they know what is going on around them – ie they don’t know that they know; and • the crew does not recognise that they don’t know what is going on around them – ie they don’t know that they don’t know.

Appropriate decision making must make allowance for which section of the matrix the crew identifies they are in which, by definition, is impossible for the last section.

When ‘the crew recognises that they know what is going on around them’, decision making is likely to be accurate, and any faulty decision making will be a function of applying the wrong rule to the correctly identified situation. This of course assumes that there is a rule or procedure to be applied – a subject discussed later.

When ‘the crew recognises that they don’t fully understand what is going on around them’, rule based decision making as is currently espoused is inappropriate.

However, there is a generalised form of rule based decision making that can still be applied in these situations – ‘IF you recognise that you don’t fully understand the situation you find yourself in, THEN make conservative decisions that give you time, or that allow you to return the situation to something you do fully understand’.

In some unusual and unprecedented cases this may be impossible, but the ‘if/then’ rule of being conservative and working to normalise or at least stabilise as much of the situation as possible, remains.

The next scenario, when ‘the crew does not recognise that they know what is going on around them’, can largely be summed up by saying the crew is confused. In these sorts of situations, the standard cyclical decision making models which use acronyms such as PLANE, DECIDE, CLEAR, SADIE etc are very useful. Cycling through these models should place the crew on a trajectory towards resolving any confusion, which is a trajectory towards the first ‘know that they know’ box from which they will be able to make an appropriate decision. However, while they are going through this process, by default they are in the previous ‘know that they don’t know’ part of the matrix, so the only rule they can apply is the ‘if/then rule of conservatism’ as previously mentioned.

The remaining part of the matrix is when ‘the crew does not recognise they don’t know what is going on around them’.

Appropriate decision making in this segment is impossible – you can’t make appropriate decisions about something you don’t even recognise is happening. By definition, it is also impossible for you to recognise that you are operating in this area of the matrix. The dangers of allowing yourself to continue to operate in this box can be summed up by the well known saying – ‘accidents don’t happen because people gamble and lose, rather they happen because the individuals concerned are oblivious to the inevitability of the accident or incident that is about to happen’.

The only way that the potentially catastrophic threat that this section of the matrix represents can be managed is by a constant operational vigilance to ensure you remain in one of the other three sections – with continuous pressure being applied to return to the first section, where standard versions of ‘if/then’ rules or procedures can be applied. Or, to put it another way, in the ‘don’t know that you don’t know box’, it is impossible for you to know that you have lost situational awareness. Hence the only way you can ensure you maintain appropriate situational awareness is continuous operational vigilance and pressure to remain well within both your, and your crew’s, circle of competence by using standard operational processes and procedures.

As per a previous article in this ongoing series, it is also important to recognise that cognitive overload, caused by either time pressure or information overload or a combination of both, can result in the crew being suddenly placed in either the ‘don’t know that they know’ or ‘don’t know that they don’t know’ boxes of the decision making matrix. Attempting to make any operational decision in these areas, other than a strictly conservative decision such as a missed approach, entering a holding pattern, delaying a takeoff etc, is ultimately just guessing, and where the outcome is dependent on luck.

This matrix also has a third overlying dimension – expertise. As has already been argued in previous articles, experience and expertise are very different – you need experience to build expertise, but experience by itself is only hours in a logbook.

As your expertise increases your ability to recognise situations will improve, as will your ability to recognise what information is missing, or misleading, and needs to be resolved. This then allows you to use the fast and seemingly effortless decision making processes experts use in situations they fully or partially recognise, where they may ‘cobble’ together many partial or incomplete recognition primed ‘if/then’ rules or procedures as appropriate. A crew’s (or an individual’s) expertise can be operationally considered as both an increase in the size of the first section of the matrix where ‘the crew recognises that they know what is going on around them’, and also as an increase in their ability to recognise when they don’t know something, ‘the know that they don’t know’ section, so they are able to take positive steps to return to the first section before the operating environment demonstrates to them they are ‘out of their depth’.

The aeronautical operating environment is dynamic, and hence the situation you are operating in is permanently changing – whether you recognise it or not. As a result, good dynamic threat and error management means you must continuously and proactively make decisions to ensure you remain within your circle of competence, since decision making outside this area is about the same as night flying without any instruments – you will need luck and clear skies to get away with it.

You can’t make appropriate decisions about something you don’t even recognise is happening.