The Limits of Expertise by Dismukes, Berman, Loukopoulos

The Limits of Expertise by Dismukes, Berman, Loukopoulos is the book titled The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents (Ashgate Studies in Human Factors for Flight Operations) and authored by R. Key Dismukes, NASA Ames Research Center, California, Benjamin A. Berman, NASA Ames Research Center/San Jose State University Foundation, California, and Loukia D. Loukopoulos, NASA Ames Research Center/San Jose State University Foundation, California, and published by Ashgate Publishing Limited, Aldershot, Hampshire, England and Ashgate Publishing Company, Burlington, VT USA in 2007.

The copyright belongs to R. Key Dismukes, Benjamin A. Berman and Loukia D. Loukopoulos.

• Approach. Procedures and parameters that define the manner in which an aircraft will approach the destination airport and ultimately land. Pre-defined approaches are published for each airport - one runway at a large airport may be reached using several different kinds of approaches, depending on the weather conditions and the technology in use. Common types of approaches include:
  • visual approach: conducted in visual reference to terrain;
  • instrument approach: conducted using instrument references;
  • precision/non-precision approach: with/without an electronic glideslope;
  • ILS (instrument landing system) approach;
  • coupled approach: flown by an autopilot that is coupled to the flight controls;
  • missed approach: transition from descending on the approach to climbing to a preestablished missed approach altitude;
  • final approach: the final portion of the approach that terminates with the landing;
  • stabilized approach: a final approach descent that is stabilized with respect to a number of parameters, typically including airspeed, aircraft configuration (gear down and flaps set), establishment within on-course and on-glidepath tolerances, and engine thrust;
  • unstabilized approach: violation of any of these criteria at a specific altitude above ground or distance from the runway.
• ASAP. Aviation Safety Action Program: a voluntary program in which pilots and other airline personnel report incidents to a joint company, labor union, and FAA panel that decides on corrective actions and provides the reporters, in turn, with limited immunity from FAA sanctions.
• ASRS. Aviation Safety Reporting System: incident reporting system run by NASA. It collects voluntarily submitted aviation safety incident reports from pilots, air traffic controllers, flight attendants, mechanics, ground personnel, and others involved in aviation operations. Analysis of the de-identified data helps identify deficiencies in the National Aviation System, and supports efforts taken towards their resolution and prevention. More than 600,000 reports have been submitted to date.
• Availability heuristic. Information that is used frequently is retrieved from long-term memory more readily than infrequently used information. This can bias individuals to overestimate the probability of events for which they can readily retrieve information.
• Bad apple theory. The belief that the overall operation of a complex system would be optimal and reliable if the erratic behavior of some unreliable operators were somehow eliminated.
• Briefing. Verbal conference conducted between the pilots before the beginning of certain phase of workload that will be requiring coordination and therefore an agreed-upon plan; for example, before takeoff, or before starting an approach to the destination airport. A briefing is also conducted between flight crew (pilots) and cabin crew (flight attendants) prior to a sequence of flights. In their standard operating procedures, many carriers specify the important points that must be covered in a particular briefing.
• Callout. Specific utterances made by the monitoring pilot that serve to aid and enhance the general situational awareness of the flying pilot. Callouts are specified by each air carrier's standard operating procedures, most often refer to instrument readings, and are specific to each flight phase (for example, during the takeoff roll the monitoring pilot will call out the aircraft speed as indicated by the airspeed indicator - "100 knots"… "V1"… "Rotate"). In some cases, callouts are indicated only if certain parameters have been exceeded and the ongoing action must be discontinued (for example, during the approach to landing, the monitoring pilot will call out the deviation from any of a number of parameters for a stabilized approach, as set forth in the flight operations manual).
• Challenge. A verbal utterance made by the monitoring pilot to alert the flying pilot that a specific flight parameter limit has been exceeded or an undesired aircraft state is occurring. These challenges are specified in airline standard operating procedures as a required function of the monitoring pilot; thus they do not connote interpersonal friction or insubordination. Besides being meant to inform the other pilot, they are also intended to prompt the other pilot to respond. Challenges must continue until any adverse situation is corrected. See also checklist, for another context in which this term is used.
• Change blindness. Failure to notice changes in a visual scene. Because noticing such changes effectively depends on comparing two images (that is, the two versions of the visual scene), change blindness may be related to memory - a failure to store information about the first image, or a failure to compare the second (current) with the first (earlier) image.
• Check airman. Airline pilot who is qualified to evaluate the performance of other pilots.
• Checklist. List of actions to be accomplished prior to a particular event (such as a takeoff) that, when executed in the specified order, help ensure that the aircraft and its crew are ready to safely undertake that event. Checklists typically refer to actions already accomplished by memory (that is, in the course of a procedure), thus adding a layer of protection against errors and omissions and verifying that critical procedural steps ("killer items") have been accomplished. Checklists referred to in this book are read from a printed, laminated card and are executed in a challenge-and-respond manner. When a checklist is called for by the flying pilot, the monitoring pilot locates and physically holds the checklist card, challenges (reads out loud) each line and verifies that the intended action has already been performed and the expected outcome has been achieved (for example, when the checklist calls for the engine ignition switches to be turned on, the pilot visually confirms that they are on by looking at the switches). The monitoring pilot must then utter a verbal response to confirm that the intended action has been accomplished using the exact verbiage prescribed. Some checklists involve one pilot challenging the item and the other pilot confirming and responding with the proper response. Once the specified actions have been challenged and responded to, the monitoring pilot announces the checklist "complete." One other type of checklist referred to in this book is a mechanical checklist located on the center aisle panel between the pilots that allows them to move a switch to reflect completion of each item, thus keeping better track of their progress along the checklist.
• Check ride. Airline pilots are periodically given "proficiency checks" in which they are required to perform challenging normal and abnormal procedures in a high-fidelity flight simulator, and they are also given "line checks" in which a senior captain - a check airman - flies with the pilot being checked on a regular line flight to evaluate performance and adherence to company procedures.
• Confirmation bias. A tendency to seek and use information that confirms a hypothesis or belief, and not notice or use information inconsistent with the hypothesis or belief.
• CRM. Crew resource management: a set of principles that pilots and others are taught to use to make effective use of all available resources - human, equipment, and information. Interaction and coordination among team members are emphasized. The concept of "team" includes but is not limited to flight deck crewmembers, cabin crew, air traffic controllers, dispatch, and maintenance. CRM principles are couched in various ways but in general address topics such as workload management, coordination and communication, leadership and support, situation awareness, and decision-making.
• D/b/a. Doing business as (equivalent to UK t/a, trading as).
• Declarative knowledge. Knowledge to which individuals have conscious access and can report directly (verbally or otherwise).
• Deterministic. The future status of a deterministic system can be accurately predicted based on its history.
• FAA. Federal Aviation Administration (of the US). The government agency that regulates flight operations and safety aspects of commercial aviation in the US.
• FDR. Flight data recorder: equipment that records parameters involving aircraft motion, engine status, and in some installations control inputs, control surface movements, and the status of various other aircraft systems. The data are shielded in a crashresistant case. The number of parameters varies from 13 on older systems to hundreds on modern systems.
• Final report. Most major aviation accident investigations performed by the NTSB result in a detailed final report known as a "Bluecover" report (the name is derived from an earlier - but not current - color scheme) that follows the ICAO Appendix 13 format for an accident report, first summarizing relevant factual information about the accident, then analyzing the facts, and finally reporting the agency's findings, causal determinations, and recommendations for safety improvement. Such a report was available for 17 of the 19 accident cases that we review in this book. Sometimes the NTSB publishes the results of a major investigation in a less extensive, "summary" or "brief format" report. In most of these summary reports the discussion of the facts and analysis of the accident is much less extensive than in a Bluecover report. For the two major accident cases we analyze for which the NTSB did not produce a major accident report, we also reviewed publicly available background reports by NTSB investigators ("group chairman factual reports") in the areas of flight operations, human performance, and data recorders.
• Fix. Geographic location that airplanes can navigate to or from using radio or other electronic navigation technologies. Flight plans, routes, and approaches are composed of a series of fixes.
• FOM. Flight operations manual (also flight operating manual): multi-volume reference document specifying basic design characteristics, specifications, and performance constraints of the aircraft, as well as the carrier's standard operating procedures for operating the aircraft. These guidelines define the intended use of the aircraft so that it meets both safety and efficiency goals as set forth by the manufacturer and the carrier. Each air carrier authors its own FOM based largely on the manufacturer's operations manual and according to specific guidelines set forth by the FAA.
• FOQA. Flight operations quality assurance: voluntary air carrier safety program that involves the routine monitoring of many parameters of flight operations for events that exceed safe limits and the analysis of trends over time.
• Flying pilot. The pilot who controls the aircraft in flight. This is different from the pilot in command who is responsible for the flight and is always the captain by virtue of positional authority. The flying pilot manipulates the control yoke, thrust levers, and MCP/FMC settings. See also monitoring pilot.
• Go-around. Aborted landing of an aircraft. Pilots are always ready to execute a go-around, according to a specific procedure, if certain criteria for a stabilized approach have not been met in the final stages of an approach.
• GPS. Global positioning system: constellation of satellites that provides extremely accurate position information to aircraft that are equipped with a GPS receiver.
• Hindsight bias. Natural human tendency to evaluate past actions and decisions in light of what is now known about that situation. This bias can lead accident investigators, for example, to oversimplify the situation faced by an accident crew and to assume that things that are blatantly obvious to all after-the-fact should have also been equally obvious to the accident crew at the time they arose.
• ICAO. International Civil Aviation Organization: International organization associated with the United Nations that establishes standard practices and recommended practices for aviation operations.
• Inattentional blindness. Failure to notice a visible but unexpected stimulus because attention is focused on some other aspect of the viewed display. Unlike change blindness, it does not appear to be linked to short-term visual memory as it does not require comparing images stored in memory.
• Local rationality assumption. Principle that one should try to understand how past actions and decisions made sense in the moment, given the "local" circumstances at that time. Avoiding the influence of hindsight bias, a pilot's behavior can be understood as rational when assessed in light of the incomplete knowledge, goals, frame of mind, and pressures that the pilot was trying to balance and address at the time of the (erroneous) decision or action.
• LOFT (line oriented flight training). Training provided to flight crews using a high-fidelity flight simulator that incorporates realistic scenarios and challenges crews to manage abnormal situations in real time.
• LOSA (line operations safety audit). Voluntary air carrier safety program, endorsed by the FAA and ICAO, that involves the collection of data on crew, organization, and system performance. The LOSA methodology was developed in the late 1990s by the University of Texas Human Factors Research project in conjunction with major US airlines. Using observations from routine flights and structured interviews of crewmembers, it enables the systematic assessment of operational threats and cockpit crew errors and their management.
• MEL. Minimum equipment list: FAA-approved document that authorizes dispatch of a flight with specified equipment inoperative, including the required maintenance actions and any operational conditions that are required to ensure safety.
• Norms. Practices that are not written and required but are common practice. Norms may deviate from formal procedures when the latter do not allow human operators to perform their jobs efficiently and/or safely, or are not enforced. Routine deviation from formal procedures may occur repeatedly without mishap and come to be perceived (often incorrectly) by operators to involve little risk and in time become common practice.
• NTSB. National Transportation Safety Board (of the US): US government agency responsible for investigating and determining the probable cause of civil aviation accidents.
• Overhead panel. Collection of gauges, switches, and indicators located over the pilots' heads and extending from above eye-level to almost behind their heads.
• PFD. Primary flight display: an aircraft instrument combining various pieces of information that were in the past displayed on separate instruments (such as airspeed, altitude, vertical speed, turn and bank information, radio navigation information).
• Plan continuation bias. Failure to revise a plan of action when the situation diverges from the premises on which the plan was originally built. For example, pilots may fail to recognize that changes in weather conditions along the intended flight path make the original plan inappropriate.
• Power distance. Degree to which the less powerful members of a group expect and accept differences in the levels of power among group members.
• Probabilistic. Situations in which the outcome cannot be uniquely determined from the initial conditions. Random variations among contributing factors allow a range of possible outcomes that can only be described statistically.
• QRH. Quick reference handbook: an indexed handbook commonly provided by air carriers for pilots to use for performing checklists for emergency and abnormal situations; the QRH also may include performance data and other information that pilots need to be able to obtain readily while in flight.
• Recognition-primed decision-making. A theoretical construct within the field of naturalistic decision-making (decisions made by experts within their domain of expertise). This construct, supported by empirical evidence, asserts that experts usually do not formally analyze the characteristics of situations and assess options sequentially. Rather, experts recognize the essential characteristics of situations from previous encounters stored in memory and quickly generate a response option that "satisfices" rather than optimizes. The response option is often evaluated through mental simulation.
• Source memory. Memory for the context in which a piece of information was originally learned.
• TSA. Time since awakening.
• Working memory. A system in which memory items are temporarily retained in a state of high availability to facilitate performance of tasks at hand. Items not in current use revert to long-term memory, from which access is generally slower and more effortful.