“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,… More >>
The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents
Tags: accidents, airline, airline accidents, aviation accidents, causal factor, Causes, cognitive processes, Error, Expertise, human error, industrial engineering, Limits, national transportation safety, national transportation safety board, ntsb, pilot, pilot error, Rethinking, transportation safety board
#1 by Books Galore on January 27, 2010 - 7:20 pm
Easy transaction, book in condition it was described and received it on time…would buy from seller again.
Rating: 5 / 5
#2 by Clark on January 27, 2010 - 8:50 pm
If you are interested in the operational safety of high reliability organizations, especially the field of aviation, you must read this book. It addresses the question of why experts can still be subject to the vagaries of a complex system.
The global aviation industry is poised to move to the next higher level of safety, and the way to get there is a two part process. The first part is to encourage open identification and reporting of hazards within the system. The second part is to look for not only latent conditions and system actor actions at all levels, but also the multiple complex interactions that dynamically couple to cause mishaps. Focusing on determination of cause or probable cause is an overly simplistic and non-deterministic description of the system. The Limits of Expertise delves into those interactions between system actors and agents and brings them to light. Once we develop that clearer view, a common reality and shared mental model, we stand a better chance of understanding system behavior and preventing future mishaps. TLOE helps us develop that view.
With 30 years of experience as a safety professional and high performing team resource management expert, I put “The Limits of Expertise” as number one on my “Recommended Reading” list for operational safety personnel. The author’s approach is also a good model for operational safety professionals in other high reliability fields of transportation, nuclear power, and the medical industry.
Kent
Captain USMC (Retired)
http://www.signalcharlie.net
Rating: 5 / 5
#3 by M. Finch on January 27, 2010 - 9:18 pm
It reads like a thesis but is full of great analyses beyond the “official” accident reports. Most aircraft accidents are attributed to “pilot error.” Here, the authors dissect the human factors in several accidents and delve into human fallibilities and technical traps which make us all prone to error.
Rating: 4 / 5
#4 by Jose Sanchez Alarcos on January 27, 2010 - 11:16 pm
When someone reviews statistical information about human factors in air accidents, it is very easy to find that under the label “human factors” there are many different and heterogeneous things.
The real way to know what is the importance of human factors is an in-depth analysis of many accidents without accepting the generic “human factors” as an explanation. That is exactly what authors make with several accidents explaining beyond NTSB analysis why crew behaved in a way that, finally, drove to an accident.
The book shows a model of analysis and that is very useful for investigators or air safety experts in general. However, the application of that kind of analysis to many other accidents -all of them, if possible, instead of a few ones- should be extremely useful not only to avoid new accidents but to design new planes, new SOPs and new training models.
The conclusion we could extract is as follows: At this moment, we are not extracting all the possible knowledge from an accident. The book explains how to go further.
Rating: 5 / 5
#5 by Alan N. Hobbs on January 28, 2010 - 12:57 am
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.
Rating: 5 / 5