Real-Time Decision Making

Fourteen months ago I wrote about Coordinated Team Efforts in Health Care.
I learned about Paul Barach’s work in health teams and in my post I noted:

My ears pricked up with an early reference to “highly coordinated team efforts, leadership and a calm alignment”. Paul was discussing a team effort that drew upon routines developed in training and a team that did not panic … in the context of the response to the emergency on the Qantas QF32 flight out of Singapore recently.

This week I received an alert to another account of expert decision making in an airline incident.
Dave Ferguson has written about Flight 1549. Dave has been reading the National Transportation Safety Board report about the incident “to learn more about the interplay between training, learning, performance support, and the environment in which this emergency took place”.
The incident:

On January 15, 2009… US Airways Flight 1549…experienced an almost complete loss of thrust in both engines after encountering a flock of birds and was subsequently ditched on the Hudson River about 8.5 miles from LaGuardia Airport (LGA), New York City… The flight… had departed LGA about 2 minutes before the in-flight event occurred.

I think Dave has written a fascinating account of the incident and the report. I was particularly interested in two points he made:

  • For all of 1549′s crew–in the cockpit and in the cabin–performance resulted from experience, and experience was shaped not only through time in the air, but through regular training intended to focus on critical events, to provide feedback, and to increase the likelihood of success in critical, unpredictable situations.
  • In an interview the captain observed:

One way of looking at this might be that for 42 years, I’ve been making small, regular deposits in this bank of experience, education, and training. And on January 15 the balance was sufficient so that I could make a very large withdrawal.

Photo Credit
Door Number 3 – Decisions Decisions
Flight 1549


  1. Keith, I’m glad you found the post of interest. There were so many factors at work in this situation.
    I’m still mulling it over, and one of the lenses I find useful is the Behavior Engineering Model originally developed by Thomas Gilbert and updated a few years ago by Roger Chevalier.
    The model looks at both the environment (e.g., the work setting) and the individual, with three categories for each representing factors that influence behavior and accomplishment. For example, in terms of the environment, you look at resources such as tools, materials, and procedures. The parallel dimension for the individual is capacity: can the person learn the job? Do individuals chosen for the job have the ability to do it?
    You can see these factors at work in the NTSB’s conclusions–for example, an often-overlooked factor in the survival of the passengers is the fact that the plane was equipped for “extended overwater” flight, even though that wasn’t required since the intended route was almost entirely over land.
    I see that you focus is often on sport. While I am not a running, I was intrigued by a recent article on running technique. I’m not qualified to judge the effectiveness, but the analytical approach to what “everyone knows” was fascinating.


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