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

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Ashgate Publishing, Ltd., Jan 1, 2007 - Transportation - 352 pages
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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 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.
 

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Contents

USAir 1016 Windshear Encounter
9
TWA 843 The Power of Suggestion
25
American 1572 Accumulation of Small Errors
37
American International 808 The Strobe Light that Wasnt There
51
Southwest 1455 Unstabilized Approach at Burbank
63
FedEx 14 PilotInduced Oscillations in the Landing Flare
85
Ryan 590 A Minute Amount of Contamination
95
Tower 41 Loss of Control During a Slippery Runway Takeoff
101
Air Transport International 805 Disorientation Loss of Control and the Need to Intervene
185
American 903 Loss of Control at Altitude
197
Simmons 3641 Over the Gates and into Forbidden Territory
213
American 1340 Autopilot Deviation Just Prior to Landing
223
Delta 554 Undershot Landing at LaGuardia
233
American 1420 Pressing the Approach
247
FlightcrewRelated Accident Data Comparison of the 19781990 and 19912001 Periods
275
Converging Themes The Deep Structure of Accidents
289

Continental 1943 GearUp Landing in Houston
109
American 102 Runway Excursion After Landing
131
Continental 795 HighSpeed Takeoff Decision with Poor Information
143
USAir 405 Snowy Night at LaGuardia
159
ValuJet 558 Two Missing Words and a Hard Landing Short of the Runway
171
Glossary
309
Bibliography
331
Index
347
Copyright

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Page 331 - Arkes, HR. & Blumer, C. (1985). The psychology of sunk cost. Organizational Behavior and Human Decision Processes, 35, 124-140.
Page 333 - K. (1998). Cockpit interruptions and distractions: Effective management requires a careful balancing act. ASRS Directline, 10, 4-9.

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