The Limits of Expertise

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.

Dr Dismukes is Chief Scientist for Human Factors in the Human Factors Research & Technology Division at NASA Ames Research Center. His current research addresses cognitive issues involved in the skilled performance of pilots, their ability to manage challenging situations, and their vulnerability to error; prospective memory; and management of attention in concurrent task performance. Captain 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. He is the former Chief of Major Investigations of the U.S. National Transportation Board, where he previously led the Operational Factors Division, served as a member of the major accident go-team responsible for flight operations, and managed safety studies. Dr Loukopoulos is a Senior Research Associate at NASA's Human Factors Research and Technology Division. She currently resides in Athens, Greece where she serves as a human factors consultant to the Greek Air Accident Investigation and Safety Board and where she served on the Helios Airways 2005 accident investigation. She also continues her collaboration with NASA through the San Jose State University Foundation.

Contents: Foreword; Preface; Introduction; USAir 1016 - windshear encounter; TWA 843 - the power of suggestion; American 1572 - accumulation of small errors; American International 808 - the strobe light that wasn't there; Southwest 1455 - unstabilized approach at Burbank; FedEx 14 - pilot-induced oscillations in the landing flare; Ryan 590 - a minute amount of contamination; Tower 41 - loss of control during a slippery runway takeoff; Continental 1943 - gear-up landing in Houston; American 102 - runway excursion after landing; Continental 795 - high-speed takeoff decision with poor information; USAir 405 - snowy night at LaGuardia; ValuJet 558 - 2 missing words and a hard landing short of the runway; Air Transport International 805 - disorientation, loss of control and the need to intervene; American 903 - loss of control at altitude; Simmons 3641 - over the gates and into forbidden territory; American 1340 - autopilot deviation just prior to landing; Delta 554 - undershot landing at LaGuardia; American 1420 - pressing the approach; Flightcrew-related accident data: comparison of the 1978-1990 and 1991-2001 periods; Converging themes: the deep structure of accidents; Bibliography; Index.