"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.
Author(s): R. Key Dismukes, Benjamin A. Berman, Loukia D. Loukopoulos
Year: 2007
Language: English
Pages: 352
Contents......Page 6
List of Figures......Page 8
List of Tables......Page 9
Foreword......Page 10
Preface......Page 11
Acknowledgments......Page 12
Introduction......Page 14
1 USAir 1016 – Windshear Encounter......Page 22
2 TWA 843 – The Power of Suggestion......Page 38
3 American 1572 – Accumulation of Small Errors......Page 50
4 American International 808 – The Strobe Light that Wasn’t There......Page 64
5 Southwest 1455 – Unstabilized Approach at Burbank......Page 76
6 FedEx 14 – Pilot-Induced Oscillations in the Landing Flare......Page 98
7 Ryan 590 – A Minute Amount of Contamination......Page 108
8 Tower 41 – Loss of Control During a Slippery Runway Takeoff......Page 114
9 Continental 1943 – Gear-Up Landing in Houston......Page 122
10 American 102 – Runway Excursion After Landing......Page 144
11 Continental 795 – High-Speed Takeoff Decision with Poor Information......Page 156
12 USAir 405 – Snowy Night at LaGuardia......Page 172
13 ValuJet 558 – Two Missing Words and a Hard Landing Short of the Runway......Page 184
14 Air Transport International 805 – Disorientation, Loss of Control and the Need to Intervene......Page 198
15 American 903 – Loss of Control at Altitude......Page 210
16 Simmons 3641 – Over the Gates and into Forbidden Territory......Page 226
17 American 1340 – Autopilot Deviation Just Prior to Landing......Page 236
18 Delta 554 – Undershot Landing at LaGuardia......Page 246
19 American 1420 – Pressing the Approach......Page 260
20 Flightcrew-Related Accident Data: Comparison of the 1978–1990 and 1991–2001 Periods......Page 288
21 Converging Themes: The Deep Structure of Accidents......Page 302
A......Page 322
C......Page 326
D......Page 329
F......Page 330
G......Page 332
I......Page 333
L......Page 334
M......Page 335
N......Page 336
P......Page 337
R......Page 338
S......Page 340
T......Page 341
V......Page 342
W......Page 343
Bibliography......Page 344
C......Page 360
F......Page 361
M......Page 362
R......Page 363
V......Page 364
W......Page 365
