The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents
R. Key Dismukes
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The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents
R. Key Dismukes
"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.
Publication Year: 2007
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Every pilot should read 'The Limits of Expertise.'
Written by three scientists from the NASA Ames Research Center, 'The Limits of Expertise' is exquisitely researched and carefully composed. Best of all, it's well written!
The book consists of an introduction, nineteen case studies, and two chapters of conclusions. The case studies are riveting. As a flight standards captain with a major U.S. airline with over 30 years of experience, I could put myself in the control seat with the case study pilots every time. I, as have most other pilots, have been in situations similar to the ones described. I zigged. They zagged. Maybe someone else zogged. All of us can say, "There, but for the grace of God, go I."
In the case studies, the authors break down the steps in the causal chain that led to each of the incidents. Their great insight, in my opinion, is their repudiation of determinism. They understand that pilots, as human beings, aren't robots or algorithms. We have variations in performance, due to a wide variety of internal and external factors.
The authors combine their understanding of pilot psychology with statistical analysis in the concluding chapters, highlighting the scenarios that most airline mishaps have in common. I find this to be immediately, practically, usable: I'll brief these threats on my next trip.
Really, this is an excellent book. Its exploration of failure in high-stress, high-expertise situations is applicable to experts in a variety of fields. I can imagine versions written for physicians, first responders, and other experts who work in areas with tiny margins of error.
If you're a pilot, read this next. If you're an expert in a stressful, life-or-death field, read it soon. If you just think psychology is interesting, read it. I'll be recommending this book to my fellow pilots for years to come.
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