The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents [Paperback]

R. Key Dismukes (Author), Benjamin A. Berman (Author), Loukia D. Loukopoulos (Author)

Book Description

ISBN-10: 0754649652 | ISBN-13: 978-0754649656 | Publication Date: January 2007 | Edition: New edition

"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.

Editorial Reviews

About the Author

Dr Dismukes is Chief Scientist for Human Factors in the Human Factors Research & Technology Division at NASA Ames Research Center. Mr Berman is a senior research associate at San Jose State University/NASA Ames Research Center and flies the Boeing 737 for a major air carrier. Dr Loukopoulos is a Senior Research Associate at NASA's Human Factors Research and Technology Division.

Product Details

• Paperback: 352 pages
• Publisher: Ashgate Publishing; New edition edition (January 2007)
• Language: English
• ISBN-10: 0754649652
• ISBN-13: 978-0754649656
• Product Dimensions: 9.1 x 6.1 x 0.9 inches
• Shipping Weight: 1.2 pounds (View shipping rates and policies)
• Average Customer Review: 4.9 out of 5 stars  See all reviews (9 customer reviews)
• Amazon Best Sellers Rank: #419,707 in Books (See Top 100 in Books)

Customer Reviews

Most Helpful Customer Reviews

16 of 16 people found the following review helpful:

5.0 out of 5 stars The value of rethinking, May 4, 2007

By 

Benjamin Daley - See all my reviews
(REAL NAME)   

This review is from: The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents (Ashgate Studies in Human Factors for Flight Operations) (Hardcover)

Air travel has become remarkably safe as a result of advances in equipment systems, operating procedures and training. Each year, flight crews deal skilfully with sub-optimal systems and unexpected situations during the course of around 17 million flights world-wide. Yet airlines operate in a highly competitive market with pressures to deliver unprecedented levels of efficiency, so it is now more important than ever to understand what makes the air transport system vulnerable to failure. Since most aviation accidents have been attributed to deficiencies in the performance of flight crews, it is particularly important to understand what makes pilots vulnerable to error.

In this outstanding and original book, the authors argue that human skill and vulnerability to error are closely linked: errors occur because flight crews are expected to perform tasks at which perfect reliability is not possible - either for humans or machines. The authors show that the presence and interaction of factors contributing to error is probabilistic rather than deterministic. Accidents are rarely caused by a single factor, but rather by the complex interaction of many factors that combine in ways driven largely by chance. The authors argue that small, random variations in the presence and timing of those factors can drastically increase the probability of pilots making errors leading to an accident.

Consequently, it is crucial to understand the nature of vulnerability to error in order to reduce that vulnerability. While it is not always possible to determine exactly why accident crews did what they did, the authors demonstrate that it is possible to understand the types of error to which pilots are vulnerable - and to understand the interplay of various factors contributing to that vulnerability. The central questions posed in this book are: why do highly skilled professional pilots make errors, with consequences that are sometimes fatal to themselves and to their passengers? And how should we understand the role of these errors in accidents in seeking to prevent future accidents? The authors apply scientific knowledge of the nature of skilled performance of humans performing complex tasks to address these questions.

The book reviews the 19 major accidents in US airline operations during the period 1991-2000 in which crew errors played a central role, as defined by the US National Transportation Safety Board (NTSB), based on the NTSB reports and associated documents. While the NTSB must determine the probable cause of each specific accident, the authors take a different approach: would other pilots be vulnerable to making the kinds of errors made by the accident crew and, if so, why? This original approach reveals factors that make all pilots vulnerable to specific types of error in certain situations. In adopting this approach, the authors challenge the assumption that, if expert pilots make errors, this is evidence of their lack of skill, vigilance or conscientiousness. Instead, the authors emphasise the interactions of subtle variations in task demands, incomplete information available to pilots, and the inherent nature of skilled performance. The authors go beyond accident investigation, therefore, to explore the common themes and `deep structure' underlying the accidents.

In addition to the stand-alone accident chapters, the authors provide a statistical summary chapter that extends an earlier study by the NTSB and that reviews accident data for a longer period (1978-2001). In the final chapter, the authors identify the main themes and implications of their study, suggesting specific ways to improve aviation safety. Many issues are raised, including the significance of crew familiarity, crew fatigue, first officer experience levels, unstabilized approaches, plan continuation bias, misleading or absent cues, and monitoring/challenging errors. The authors reframe these airline accidents as `system accidents' resulting from the lack of adequate information provided to crews, the inherent difficulties of assessing ambiguous situations, and the less than extremely conservative guidance given to pilots by the air transport industry.

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 industry 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 prioritising 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. Given the nature and scope of their study, the authors have focused on the US context, yet their approach could valuably be applied to other parts of the world: a comparable study for Europe, for instance, would be revealing. Their approach could also be extended to other parts of the air transport system, such as air traffic management, where the performance of skilled experts is also implicated in some airline accidents.

The main significance of this book is in its re-framing of the causes of airline accidents: the authors argue that, if we must continue to conceive of airline accidents in terms of deficiency, then that deficiency should be attributed to the overall air transport system. Such an approach can contribute to aviation safety by providing a foundation for improving equipment, training, procedures and organisational policy. In so doing, it is possible to reduce the frequency of `system accidents' and to devise adequate protection against the types of errors to which many, if not all, pilots - as well as many other experts - are vulnerable.

14 of 14 people found the following review helpful:

5.0 out of 5 stars Breathes life into accident reports, August 9, 2007

By 

Alan - See all my reviews

This review is from: The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents (Paperback)

The authors have applied insights from cognitive psychology to nineteen flight-crew-related accidents. In place of the dry narratives of accident reports, we are presented with compelling three-dimensional accounts in which pilots are routinely faced with time pressure, the need to make judgments under uncertainty, and rare but potentially lethal system failures. In examining each accident, the authors attempt to reconstruct the mindset of the pilots, and place the actions of the crew in the context of the flow of events. In contrast to other reviews of accidents, the authors avoid the phrase "the pilots should have...". Instead we are gently encouraged to understand how skilled and professional operators can come to make mistakes in circumstances that are unforgiving of error.

Through the lens of cognitive psychology, the aviation industry becomes a massive human performance laboratory, in which hapless operators are faced with situations and problems produced not by experimenters, but by the complexities of the system of which they are a part. The authors take pains to counter the common presumption that catastrophic accidents must somehow result from extreme acts of villainy or incompetence. In this book, we repeatedly see how accidents often arise from combinations of everyday problems and situations.

By the end of the book, some fascinating patterns begin to emerge. A surprising number of the accidents involved apparently simple slips and lapses. Additionally, the majority of accidents occurred on approach and landing, and most of the accident flights were running late. The failure to go-around from an un-stabilized approach is a common theme in the accident scenarios.

On a minor note, a few more illustrations and diagrams would have added some variety to the text, and more extensive quotations from cockpit voice recordings may have helped. Overall however, the book provides a useful compendium of case studies that will be of value to industry and academia. Airline training personnel in particular will find much that is useful in this book.

12 of 12 people found the following review helpful:

5.0 out of 5 stars An excellent confluence of aviation and psychology, May 24, 2007

By 

Rahul Dodhia (Seattle, WA) - See all my reviews
(REAL NAME)   

This review is from: The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents (Paperback)

Out of approximately 10 million air carrier flights annually in the US, only about 50 involve a major accident. That may not sound like much, but those accidents consist of events like these: a Continental Airlines flight that landed without its landing gear deployed in Houston; an American Airlines flight that suffered loss of control at 16000 ft.; and another American Airlines flight that hit some trees while attempting to land, the culmination of a series of small, individually insignificant errors. These are some of the examples scrutinized in detail, drawn from a large population of accidents in which human error was a major factor. This book makes fascinating reading - providing pilots and aviation professionals with a new perspective on crew error, and the general public with a new way of looking at the whole aviation system and how safety issues are considered.

The authors dissect these accidents in a way that the airline industry has not attempted in great depth before. Rather than stopping at the facts and a conclusion of "crew error", they ask why highly skilled flight crews, with thousands of hours of flying experience, make mistakes and erroneous judgments with horrifying consequences. The common reaction after an accident is that the crew was not sufficiently skilled, otherwise they would not have made the error. The authors start with a different assumption: they assume that the crew was as good as any other crew that could have been chosen, and from that starting point, their illuminating analyses lead them to consider some very interesting psychological and operational factors that underlie these accidents.

To do this, the authors draw on their expertise on how the human brain works (memory systems and decision-making apparatus) and their complementary expertise on aviation and operations. The authors are all affiliated with NASA; two of the them are research psychologists, one of them was a major investigator with the primary transportation investigative arm of the government, the National Transportation & Safety Board, and all of them have extensive experience with aviation safety.

The book covers 19 accidents, devoting a chapter to each. Two additional chapters at the end provide statistics and a summary of the common themes and factors the authors uncover as contributing to these accidents, along with some prescription of possible countermeasures. When an airplane is involved in an accident, the National Transportation & Safety Board performs thorough investigations - these include interviews with the survivors, forensic evidence, the data from the black box, etc. The investigators produce a report that lays out the facts and their judgment of the causes of the accident.

The studies in this book take these reports as a starting point, and go down paths that the NTSB never ventures (their charter does not permit that). Each of the accident chapters is constructed to provide first a factual recount of the event and the NTSB conclusions. From here the authors identify the most significant events leading up to the accident, and for each event in turn, provide an analysis that mixes operational knowledge with cognitive functioning.

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.