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

365 Pages·2007·1.25 MB·English

by  R. Key Dismukes

THE LIMITS OF EXPERTISE
Ashgate Studies in
Human Factors
for Flight Operations
Ashgate Studies in Human Factors for Flight Operations is a series dedicated to
publishing high-quality monographs and edited volumes which contribute to the
objective of improving the safe and efficient operation of aircraft.
The series will achieve this by disseminating new theoretical and empirical research
from specialists in all relevant fields of aviation human factors. Its foundation is
in applied psychology, presenting new developments and applications in such
established fields as CRM, SA and decision-making. Its range also encompasses
many other crucial areas such as fatigue and stress, the social environment, design,
technology, communication and training.
Submitted work relevant to the objective of the series will be considered for publication
by the board of editors. The series is intended for an international readership and so
books with a broad geographical appeal are especially encouraged.
Series editorial board
R. Key Dismukes, Ph.D. is Chief Scientist for Human Factors at the NASA Ames
Research Center, California, USA.
Capt. Daniel E. Maurino is the Coordinator of the Flight Safety and Human Factors
Study Programme at the International Civil Aviation Organization (ICAO).
Sidney Dekker, Ph.D. is Professor of Human Factors and Flight Safety, and Director
of Research at the School of Aviation, Lund University, Sweden.
The Limits of Expertise
Rethinking Pilot Error and the Causes of Airline Accidents
R. Key Dismukes
NASA Ames Research Center, California
Benjamin A. Berman
NASA Ames Research Center/
San Jose State University Foundation, California
Loukia D. Loukopoulos
NASA Ames Research Center/
San Jose State University Foundation, California
© R. Key Dismukes, Benjamin A. Berman and Loukia D. Loukopoulos 2007
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system
or transmitted in any form or by any means, electronic, mechanical, photocopying, recording
or otherwise without the prior permission of the publisher.
R. Key Dismukes, Benjamin A. Berman and Loukia D. Loukopoulos have asserted their right
under the Copyright, Designs and Patents Act, 1988, to be identified as the authors of this work.
Published by
Ashgate Publishing Limited Ashgate Publishing Company
Gower House Suite 420
Croft Road 101 Cherry Street
Aldershot Burlington, VT 05401-4405
Hampshire GU11 3HR USA
England
Ashgate website: http://www.ashgate.com
British Library Cataloguing in Publication Data
Dismukes, Key
The limits of expertise : rethinking pilot error and the
causes of airline accidents. - (Ashgate studies in human
factors for flight operations)
1.Aircraft accidents - Human factors - Case studies
2.Aircraft accidents - Investigation - Case studies
I.Title II.Berman, Benjamin A. III.Loukopoulos, Loukia D.
363.1’2414
Library of Congress Control Number: 2006938316
ISBN: 978-0-7546-4964-9 (HBK)
ISBN: 978-0-7546-4965-6 (PBK)
Printed and bound in Great Britain by MPG Books Ltd, Bodmin, Cornwall.
Contents
List of Figures vii
List of Tables viii
Foreword ix
Preface x
Acknowledgments xi
Introduction 1
1 USAir 1016 – Windshear Encounter 9
2 TWA 843 – The Power of Suggestion 25
3 American 1572 – Accumulation of Small Errors 37
4 American International 808 – The Strobe Light that Wasn’t There 51
5 Southwest 1455 – Unstabilized Approach at Burbank 63
6 FedEx 14 – Pilot-Induced Oscillations in the Landing Flare 85
7 Ryan 590 – A Minute Amount of Contamination 95
8 Tower 41 – Loss of Control During a Slippery
Runway Takeoff 101
9 Continental 1943 – Gear-Up Landing in Houston 109
10 American 102 – Runway Excursion After Landing 131
11 Continental 795 – High-Speed Takeoff Decision with
Poor Information 143
12 USAir 405 – Snowy Night at LaGuardia 159
13 ValuJet 558 – Two Missing Words and a Hard Landing
Short of the Runway 171
14 Air Transport International 805 – Disorientation, Loss of Control
and the Need to Intervene 185
15 American 903 – Loss of Control at Altitude 197
16 Simmons 3641 – Over the Gates and
into Forbidden Territory 213
17 American 1340 – Autopilot Deviation Just Prior to Landing 223
18 Delta 554 – Undershot Landing at LaGuardia 233
vi The Limits of Expertise
19 American 1420 – Pressing the Approach 247
20 Flightcrew-Related Accident Data:
Comparison of the 1978–1990 and 1991–2001 Periods 275
21 Converging Themes: The Deep Structure of Accidents 289
Glossary 309
Bibliography 331
Index 347
List of Figures
9.1 Excerpts from DC-9 “Normal Checklist” 111
13.1 Cockpit Quick Reference Handbook procedure, as issued
by ValuJet Airlines (operator), for “Unable to Raise Gear Lever” 173
13.2 Checklist from Douglas Aircraft Company (manufacturer)
for “Landing Gear – Abnormal operation” 175
13.3 Company Operating Manual procedure, as issued by ValuJet
Airlines (operator), for “Unable to Raise Gear Lever” 179
List of Tables
20.1 Incidence of major, crew-caused air carrier accidents in the US 276
20.2 Rate comparison of major US air carrier accidents: “crew-caused”
and all other 276
20.3 Period of day 277
20.4 Phase of operation 278
20.5 Non-crew factors involved in accidents 279
20.6 Flight delay status 279
20.7 Time since awakening (TSA) 281
20.8 First officers with less than 1 year of experience in position 282
20.9 Crew assignment 283
20.10 Crew familiarity 285
20.11 Incidence of tactical decision errors 286
20.12 Failure to go around from unstabilized approach 287
20.13 Incidence of monitoring/challenging errors 287
Foreword
Investigators for the US National Transportation Safety Board and its sister agencies
worldwide do an extraordinary job of piecing together the evidence in major airline
accidents and determining the causes of these tragedies under the most difficult
circumstances. Every time I participated in an investigation or reviewed a staff
report, I was struck by the extent of destruction of the wreckage, the mystery of what
happened, and the difficulty of obtaining evidence. I was uniformly proud of the
work of our staff in overcoming these difficulties to unveil the causes of the accident
and to identify ways to prevent recurrence.
Crew error plays a central role in many airline accidents. Uncovering the causes
of such error is one of investigators’ greatest challenges because human performance,
including that of expert pilots, is driven by the confluence of many factors, not all of
which are observable in the aftermath of an accident. Although it is often impossible
to determine with certainty why accident crewmembers did what they did, it is
possible to understand the types of error to which pilots are vulnerable and to identify
the cognitive, task, and organizational factors that shape that vulnerability. And it is
possible to identify recurrent themes of vulnerability across a large set of accidents.
That is why this book is of essential importance. The authors go beyond accident
investigation, asking not why the accident crews acted as they did but why any
highly experienced crew in such circumstances might have been vulnerable to error.
This is not a mode of inquiry appropriate to the investigation of the causes of a
specific accident. It is, however, extremely pertinent to the development of strategies
for reducing vulnerability to error in human endeavors involving complicated
undertakings, dynamically changing circumstance, and underlying risk.
I expect that this book will profoundly influence the perspectives of accident
investigators, designers of equipment and procedures, and trainers in occupations
where professional skills are paramount. Experts are subject to the human limitations
that we all share. Improving safety requires understanding the interaction of those
limitations with task demands, operating procedures, and organizational pressures.
This understanding can provide a basis for improving equipment, training, procedures,
and organizational policy across a broad array of complex human operations.
The Honorable Carl W. Vogt
Former Chairman, US National Transportation Safety Board
Trustee Emeritus and Former Chairman, Flight Safety Foundation
Former Member, White House Commission on Aviation Safety and Security