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Despite efforts to design systems and procedures to support “correct” and safe operations in aviation, accidents still occur and errors in human judgment are found to be contributing factors. In this paper we examine how the wider aviation system may play a role in decision processes. Our strategy was to examine a collection of identified decision errors (National Transportation Safety Board [NTSB], 1994) 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 decision process model suggests that decisions with undesirable outcomes can arise in two major ways: either through misassessment of the situation - a problem with situation awareness, or through judgment of the best course of action.