When faced with dynamic and often ill-structured situations, experienced decision makers can quickly recognize and respond to the situations they encounter, a process referred to as naturalistic decision making. Naturalistic decision-making research has addressed decision-making errors in complex systems, including those that have resulted in accidents, and explained the decision making that led to the errors. Although much research has been suggested by accident investigations, little has been written about how accident investigators apply naturalistic decision-making research to decision-making errors in the accidents they investigate. The purpose of this paper is to illustrate the contribution of naturalistic decision making to accident investigation by describing how investigators explicated decision making in an accident that lacked much of the data that investigators and researchers have typically depended on to examine errors and determine accident causation.
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