The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents (Ashgate Studies in Human Factors for Flight Operations) - Softcover

Dismukes, R. Key

Softcover

ISBN 10: 0754649652 ISBN 13: 9780754649656

Publisher: Routledge, 2007

Synopsis

Why would highly skilled, well-trained pilots make errors that lead to accidents when they had safely completed many thousands of previous flights? The majority of all aviation accidents are attributed primarily to human error, but this is often misinterpreted as evidence of lack of skill, vigilance, or conscientiousness of the pilots. The Limits of Expertise is a fresh look at the causes of pilot error and aviation accidents, arguing that accidents can be understood only in the context of how the overall aviation system operates. The authors analyzed in great depth the 19 major U.S. airline accidents from 1991-2000 in which the National Transportation Safety Board (NTSB) found crew error to be a causal factor. Each accident is reviewed in a separate chapter that examines events and crew actions and explores the cognitive processes in play at each step. The approach is guided by extensive evidence from cognitive psychology that human skill and error are opposite sides of the same coin. The book examines the ways in which competing task demands, ambiguity and organizational pressures interact with cognitive processes to make all experts vulnerable to characteristic forms of error. The final chapter identifies themes cutting across the accidents, discusses the role of chance, criticizes simplistic concepts of causality of accidents, and suggests ways to reduce vulnerability to these catastrophes. The authors' complementary experience allowed a unique approach to the study: accident investigation with the NTSB, cognitive psychology research both in the lab and in the field, enormous first-hand experience of piloting, and application of aviation psychology in both civil and military operations. This combination allowed the authors to examine and explain the domain-specific aspects of aviation operations and to extend advances in basic research in cognition to complex issues of human performance in the real world. Although The Limits of Expertise is directed to aviation operations, the implications are clear for understanding the decision processes, skilled performance and errors of professionals in many domains, including medicine.

About this title

Review:

'The authors do not, however, argue that human error is just part of the price of doing business - it must still be reduced, and to be reduced, the factors associated with it must be understood as well as possible, which is the aim of their study.' AeroSafety World, May 2007 'Overall, this is an excellent and innovative text which reflects the authors' original approach to airline safety. The book is outstanding in its identification of common themes that run deeper than in previous analyses of aviation safety, and the final chapter contains clear, pragmatic guidance to the air transport and to researchers. In the final sections of the book, the authors sum up the central challenge faced by the industry in reducing vulnerability to error: pilots should be given more information, better interfaces and clearer decision-making guidance - backed up by prioritizing adherence to that guidance over commercial pressures such as on-time performance. The book will be informative for diverse readers in the air transport industry, including operational staff, researchers, safety analysts, accident investigators, designers of systems and procedures, training providers and students.' Ben Daley, Manchester Metropolitan University - Review Submitted to Amazon.com 'The Limits of Expertise challenges how we think about accidents and pilot error. From details of recent accidents, the authors argue that while pilot error is often concluded as cause, we should expect many operators similarly situated to make comparable decisions and take equivalent actions. From that perspective, individual actions and errors are not the source of accidents but a result of systemic causes. This reframing provides good news - managers and regulators can act at system levels to prevent many future accidents.' Tom Chidester, Civil Aerospace Medical Institute, USA 'This is not a Michael Crichton thriller, but those familiar with aviation will easily be able to follow the details as they are stated in factual, non-judgmental manner, and will see into the deep causes of the events that led up to the final accident. Readers who are already familiar with aviation terminology will find the book easy to read (do you know what "LOFT" and "windshear" mean?). At the end, the very helpful glossary covers both aviation and cognitive psychology terms so that readers of all levels of industry expertise or interest can enjoy this useful study.' Association for Aviation Psychology Newsletter, Sept 07 'The book is likely to be of interest to several audiences. Certain chapters may be excellent accompanying material for introductory or advanced Human Factors courses. Also, many human factors and safety professionals may find reading the book rewarding - the reports are well written and clear, even for people without aviation background. Technical concepts are explained in a glossary at the end of the book. The concluding chapter provides some insights and analyses, even though it does not constitute (and probably does not aim to be) a major theoretical proposition. Perhaps the most important aspect of the book, which makes it valuable reading for human factors professionals, is the very realistic depiction of actual operations in a complex environment. Rarely does one have the opportunity to obtain such close looks at the reasoning and actions of highly skilled professionals, such as airline crews. ' Human Factors & Ergonomics Newsletter, no2/2007 'I strongly endorse this text as a companion to the primary texts used in courses in Human Factors in Aviation or Crew Resource Management. As I prepared my syllabus for an upcoming CRM course, I found this text, reviewed it and then added it as a supplementary text to my primary CRM text...Key Dismukes ...said that he and the other authors had intended their text to be used in this unique way.' Todd P. Hubbard, International Journal of Professional Aviation Training & Testing Research 'It's usefulness and appeal may ...seem to be limited to those in aviation industries, but this is not the case. It is valuable to safety practitioners and theorists in general, particularly those in the field of human factors, and the management lessons that it draws from its many accident studies are instructive to managers in all sectors' Safety Critical Systems Club Newsletter 'The authors argue that human error should be seen as an indication of "system vulnerability" rather than pilot inadequacy. Fortunately there are many ways in which managers and regulators can improve the system to help avoid future accidents. The book is packed with techniques by which individual pilots can reduce their vulnerability to error and thereby improve their chances of reaching retirement unscathed. A fascinating read for pilots, managers, regulators and anyone interested in operations at the limits of human expertise.' The Log, BALPA, 2008 'It is not often that one finds a book that so admirably combines scientific theory and practical operations analysis. The authors do so with insight and integrity, and both professionals and the general public would be well served if more books such as this were available.' Ergonomics in Design, Spring 2008

Synopsis:

"The Limits of Expertise" reports a study of the 19 major U.S. airline accidents from 1991-2000 in which the National Transportation Safety Board (NTSB) found crew error to be a causal factor. Each accident is reported in a separate chapter that examines events and crew actions and explores the cognitive processes in play at each step. The majority of all aviation accidents are attributed to human error, but this is often misinterpreted as evidence of lack of skill, vigilance, or conscientiousness of the pilots. Why would highly skilled, well-trained pilots make errors performing tasks they had successfully executed many thousands of times in previous flights? The approach is guided by extensive evidence from cognitive psychology that human skill and error are opposite sides of the same coin. The book examines the ways in which competing task demands, ambiguity and organizational pressures interact with cognitive processes to make all experts vulnerable to characteristic forms of error.

The final chapter identifies themes cutting across the accidents, discusses the role of chance, criticizes simplistic concepts of causality of accidents, and suggests ways to reduce vulnerability to these catastrophes. The authors' complementary experience allowed a unique approach to the study: accident investigation with the NTSB, cognitive psychology research both in the lab and in the field, enormous first-hand experience of piloting, and application of aviation psychology in both civil and military operations. This combination allowed the authors to examine and explain the domain-specific aspects of aviation operations and to extend advances in basic research in cognition to complex issues of human performance in the real world. Although "The Limits of Expertise" is directed to aviation operations, the implications are clear for understanding the decision processes, skilled performance and errors of professionals in many domains, including medicine.

About this edition

• Publisher: Routledge
• Publication date: 2007
• ISBN 10: 0754649652
• ISBN 13: 9780754649656
• Binding: Paperback
• Edition number: 1
• Number of pages: 368